MAY THE FOURTH BE WITH YOU! To celebrate this International STAR WARS Holiday, we are bringing you Episode 2 of our tetralogy spotlighting a new frontier in veterinary medicine. In this episode of "A New Hope For Dogs With Mitral Valve Disease" we speak with one of the galaxy's most renowned veterinary heart surgeons, the Jedi Master, Dr. Chris Orton, to discuss more specifics on TEER| V-Clamp, the groundbreaking procedure that he and his team at Colorado State University have pioneered over the last 2 years.
In episode 1 we gave an overview of the new medical breakthrough, which Dr. Orton and his team have pioneered at Colorado State University. The new minimally-invasive procedure is called Transcatheter Edge To Edge Mitral Valve Repair (also known as TEER or the V-Clamp Procedure), and this new technology has completely revolutionized the way mitral vale disease (MVD) can be treated in dogs.
Now in episode 2, we discuss more specifics of the new procedure and how it works to repair the mitral valve, as well as
comparisons between TEER and open heart surgery. This is truly a new frontier of veterinary medicine. Stay tuned for the rest of the TEER trilogy (or tetralogy -no pun intended) where we will discuss patient selection, Dr. Orton's journey to becoming a leading authority in veterinary heart surgery, and more.
The main advantages of TEER compared to open heart surgery for mitral valve repair include safety/ low-risk, quick recovery, cost, and availability. It is inherently minimally invasive. In the future, the procedure will become much more widely available, as more centres will be able to offer the procedure. Dr. Orton and his team at Colorado State University are committed to training other centres to help bring this amazing new treatment to more dogs with mitral valve disease.
TEER uses transesophageal echocardiography and fluoroscopy to guide placement of the V-Clamp device (developed by Hongyu Medical in Shanghai, China) to reduce the leak (backwards flow of blood) across a diseased mitral valve. The clamp mainly works by addressing prolapse of the valve.
We hope you enjoy this episode! Please leave your questions and comments below!
RELATED CONTENT ON OUR CHANNEL:
-A New Hope (Ep.1) For Dogs With Mitral Valve Disease (MVD): TEER V-Clamp Overview
-Dog Heart Murmur -What Does It Mean? Is it Serious?:
-The Amazing World Of Veterinary Cardiology:
-IT'S NOT OVER! Grain Free Dog Food & Heart Disease│Twin Trees Vet Talk (FREE VET ADVICE PODCAST)
-Congestive Heart Failure in a Dog / CHF
- 3 Tips from the Emergency Vet
-1.7 Preventative & Wellness Care for Pets (Dangers to Avoid #7 of 7)
-Genetic Heart Disease
-LEARN MORE: TEER Info sheet form Dr. Orton's team at CSU:
-CSU veterinary team performs first-ever heart valve procedure on schnauzer (Feb, 2020)
- Liu B, Leach SB, Pan W, Zheng F, Jia L, Zhou X, Li J. Preliminary Outcome of a Novel Edge-to-Edge Closure Device to Manage Mitral Regurgitation in Dogs. Front Vet Sci. 2020 Dec 17;7:597879. doi: 10.3389/fvets.2020.597879. PMID: 33392290; PMCID: PMC7773927: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7773927/
-photo credit: Instagram: @corgnelius
-Diet-associated DCM update from Lisa Freeman (Board-Certified Veterinary Nutritionist at Tufts University):
-Orthopaedic Foundation for Animals:
-AKC Guide to Responsible Pet Breeding:
0:47 Intro: Christopher Orton, DVM, PhD, DACVS
1:01 What does the video show? Accessing the heart, transesophageal echocardiography, fluoroscopy.
2:18 Mitral Valve Disease Background, valve prolapse
03:10 how the V-clamp works to repair the leak
03:48 The cost of the procedure
It started with a trip to Shanghai Jan 2020, TEER in humans
04:20 credit to Hongyu Medical in Shanghai, China for making second clamp free
05:14 Contrasting open heart surgery for mitral valve repair. Advantages of TEER: minimally invasive, safety, quick recovery, availability
7:31 Survival data
8:20 Open heart surgery reduces the leak more, but is riskier, longer recovery, but outcomes are similar
Thank you Dr. Orton!
[TEASER]: So we go above and below the valve ,using Imaging, we grasp the bowel and then the clamp comes together and the two portions of the leaflet that are not meeting each other - it brings them together. Because we are now getting better at the technique, in several dogs we're putting in two clamps. If you're older, if you're not a good candidate for open heart surgery, then currently they feel very good about edge to edge repair for those people. Potentially it will be more affordable, it will be much more widely available [Music]
[Dr. Lopez]: Today we have a very special guest, the great Dr Chris Orton. He is one of the top cardiothoracic Veterinary surgeons in the world. Thank you so much for joining us.
[Dr. Orton]: Well thank you so much for having me.
[Dr. Lopez]: Can you tell us what the video is showing?
[Dr. Orton]:The video kind of collects everything that's going on in the operating room. In dogs, we access the bottom of the heart with a very small incision (about one inch) to show the heart, and then we introduce the device through the bottom of the heart. The heart continues to beat during the procedure. It is truly minimally invasive. The procedure is done under guidance of ultrasound or echocardiography, and there's three different views that the ultrasound gives us : two two-dimensional views and actually a three-dimensional view as if you're looking down on the valve.
[Dr. Lopez]:The ultrasound probe- do you just feed that down the esophagus right over the heart while the patient is anesthetized?
[Dr. Orton]: That's right- so it's trans-esophageal echocardiography. So the probe is actually right next to the heart- that gives us the best view. We also use fluoroscopy, which shows us the actual device as it's being manipulated.
[Dr. Lopez]: It's almost like a video x-ray so you can watch the device as it's advancing .
[Dr. Orton]:In the video you'll also see the operators doing the procedure, and then you'll see the patient's vitals on the lower right hand side. So the disease in dogs is actually very similar to the disease in humans. It is a condition associated with aging- it is a degenerative condition and you may have heard the term mitral valve prolapse, but what happens with this condition- the leaflets become thick and abnormal but mostly the leaflets have abnormal motion. So rather than coming together in the middle of the valve, one of the leaflets will either prolapse or flail and not meet the other leaflet, and that allows a leak, and that tends to be progressive. Now in dogs and in humans if left untreated, the leak will get worse and worse and eventually drugs will be needed and eventually dogs will succumb to congestive heart failure. Now basically when we do this technique, it's a clamp, so we go above and below the valve, using Imaging, we grasp the valve and then the clamp comes together and brings the two portions of the leaflet that are not meeting each other- it brings them together. Now this creates a double orifice of the valve, but this has been shown to be very well accepted. And one of the remarkable things that we see when we apply the clip is that the heart rate immediately falls and the blood pressure goes up because the leak has been reduced.
[Dr. Lopez]: What would be the cost of this type of a procedure?
[Dr. Orton]: Well the device is expensive- it's just over seven thousand dollars for the device, and the procedure to put it in costs about that, so it's not inexpensive. But it is favorable when you think about open heart surgery, which is much more expensive.
[Dr. Lopez]: Like in the $40-50k range?
[Dr. Orton]: Yes, that's my understandingm plus international travel. Except one important aspect of that is, because we are now getting better at technique, in several dogs we're putting in two clamps. One of the things that the company Hongyu Medical has agreed to is that the second clamp is free, so once an owner purchases one clamp, if their dog needs more than one clamp to reduce the leak (and I think that's going to become more and more common) then the second clamp is no charge.
[Dr. Lopez]: That's amazing. If they have really good medical insurance for their pet - is this something that their insurance company might cover?
[Dr. Orton]: We have had insurance companies cover this procedure. We do not currently consider this procedure experimental. We did do an early feasibility clinical trial for the first cases- that has ended. So it's really up to the insurance companies, but they may. This will become standard of care at some point.
[Dr. Lopez]: Can I ask you a couple more questions about how it compares to open heart surgery?
[Dr. Orton]: Each procedure has its advantages and disadvantages. We could talk about that. In order to do open heart surgery, you need a heart lung machine, you need to divert all the blood from the patient to a machine that's going to pump the blood and oxygenate the blood and then return it on the other side of the heart. The heart is stopped so that you get access directly to the mitral valve in order to repair it. The mitral valve is inside the heart. Generally, open heart surgery is a four to five hour surgery, and obviously is about as invasive of a surgery as can be performed. This procedure on the other hand takes about an hour and a half to two hours to do- the portion when we're in the heart is usually five to ten minutes. We're only in there for a very short period. As someone who has done open heart surgery on small dogs with mitral valve disease, there really isn't anything that you can conceive of that's more invasive and perhaps risky than open heart surgery on a small older dog. It's got very limited availability, it's expensive, it involves international travel, so it doesn't have the ability to help very many dogs. This procedure on the other hand is appealing for a couple of reasons: one by nature it's a beating heart procedure, relatively low risk. We've now done approaching 50 patients over the last two years with no dogs dying during the procedure. Now they still perform open heart surgery in humans for mitral valve disease- it has its place, and I think open heart surgery will still have a role to treat dogs with mitral valve disease. The other widely performed procedure in humans is now the edge to edge repair. This is called the Mitra Clip device and this is a beating heart surgery. In humans, it is percutaneous- that means they apply the clip through a vessel. Something close to 150,000 human patients have had this procedure.
[Dr. Lopez]: When mitral valve disease advances so far that they end up in the emergency room with congestive heart failure- at that point the owners are told about median survival times of like 6 to 12 months.
[Dr. Orton]: You're exactly right - once animals go into congestive heart failure and need diuretics, their survival is in terms of months. In dogs we've only been doing this procedure for two years, so we don't yet know the true survival advantage.We are getting better and better at doing the technique and reducing the leak. Some dogs we have reduced the leak down to almost nothing, and if that dog is 9 or 10 years old, what we would predict is that dog will die of something other than heart disease. Now we do have understanding in people comparing this technique with open heart surgery and again each has its advantages. In general, open heart surgery is better at reducing the amount of leak than Edge to Edge, but it is also riskier and carries a much longer recovery time. Edge to Edge, the advantages of course are the very quick recovery, the safety of the procedure or the risk associated with the procedure, it doesn't reduce the leak as much but the interesting thing is when they did studies in people comparing these two techniques, the long-term outcome as far as survival and avoiding hospitalizations at two, three, five years was very similar between the two. So if you're a young person at low risk for open heart surgery, a lot of times the cardiologists and cardiac surgeons are going to recommend open heart surgery. But if you're older, if you're not a good candidate for open heart surgery, then currently they feel very good about edge to edge repair for those people. I don't think open heart surgery will necessarily go away, but I'm excited about this because potentially it will be more affordable, I think it will be much more widely available compared to open heart surgery; the recovery is the most satisfying thing and what makes me as a heart surgeon feel very good about doing this procedure. I've truly been amazed- dogs have walked outside the same day as the procedure. Virtually all dogs walk outside the morning after the procedure. They can generally be discharged from the hospital on the first or second post-operative day, and we usually clear them to travel home by the third or fourth day.
[Dr. Lopez]: That's amazing. We are very enthusiastic about what this might mean. So getting the information out is good- I worry a little bit that we might be overwhelmed with cases, but we're doing the best we can to get other centers going.
Thank you [Music]