On today's episode of Twin Trees Vet Talk, we have the honour and privilege of hosting the great Dr. Chris Orton. He is a veterinary heart surgeon at Colorado State University, and is one of the leading veterinary cardiac surgeons in the world. He is highly regarded for having started the world's first veterinary open heart surgery program many years ago.
In this episode (part 1: overview) we discuss a 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.
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 the specifics of the new procedure and how it works to repair the mitral valve, patient selection, comparisons between TEER and open heart surgery, 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.
We hope you enjoy this episode! Please leave your questions and comments below!
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- 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
0:42 Intro: Christopher Orton, DVM, PhD, DACVS
1:24 Mitral Valve Disease Background
01:56 It started with a trip to Shanghai Jan 2020, TEER in humans
03:05 credit to Hongyu Medical in Shanghai, China
03:16 This new procedure has revolutionized the treatment of canine mitral valve disease
03:44 Contrasting open heart surgery for mitral valve repair
04:39 Advantages of TEER: minimally invasive, safety, recovery, availability
05:06 Pioneering TEER and training new centres
06:47 The quick recovery
7:29 Refining the technique and sharing the knowledge
7:45 Patient criteria: age, weight, stage of MVD
9:15 The procedure
10:19 how to sign up
11:25 Thank you Dr. Orton!
[TEASER] This is going to be a very important advance in the field of Veterinary Cardiology. Dogs have walked outside the same day as the procedure. It is truly minimally invasive. Compared to open heart surgery, the recovery is the most satisfying thing. In some dogs, we have reduced the leak down to almost nothing. This new procedure- it's completely revolutionized how mitral valve disease can be treated. This will become standard of care at some point.
[Dr. Lopez]: Today we have a very special guest, the honour and the privilege, the great Dr Chris Orton. He is a veterinary heart surgeon at Colorado State University, and one of the top cardiothoracic veterinary surgeons in the world. He's basically the OG of veterinary heart surgery, and he's highly regarded for starting the first veterinary open heart surgery program in the world. Thank you so much for joining us.
[Dr. Orton]: Well thank you so much for having me. I'm not sure I'm worthy of that introduction.
[Dr. Lopez]: It's amazing to have you here, and we're so excited to share this amazing new medical breakthrough.
[Dr. Orton]: I'm very excited about this new procedure. Mitral valve disease without a doubt is the most important heart disease in dogs. It is one of the most common reasons why an older dog will die, especially a small breed dog. Approximately seven percent of dogs will get this disease. Once animals go into congestive heart failure and need diuretics, their survival is in terms of months. We feel quite confident that this procedure is going to prolong that- how much we don't know. It all started with a trip to Shanghai January of 2020. The concept of a less invasive "beating heart" mitral valve repair had already been established in human patients. Something close to 150,000 human patients have had this procedure. The company in Shanghai known as Hongyu medical decided to make a canine specific device. No such device was really available in the Western World. When I saw that the Chinese had developed a device to do "edge to edge repair," I was very interested, and I signed up to go to Shanghai to see what it was about. Because of the COVID pandemic, we were there just as the pandemic was breaking out. We came home and it was a year before we were able to try this in dogs in the Western World .
[Dr. Lopez]: This is so recent.
[Dr. Orton]: I give this company Hongyu medical a lot of credit for making a canine device. They've been super supportive of us to help us bring this to dogs in the west.
[Dr. Lopez]: When do we ever get to give good news when there is heart failure? It's always the beginning of the end....This has completely changed everything. Short of a very invasive open heart procedure that's out of reach for almost everybody, we didn't really have anything to offer these heart patients. And now, there's this new procedure. It's completely revolutionized how mitral valve disease can be treated for so many patients.
[Dr. Lopez]: Yeah, so that's exactly the way we think of it. As someone who does open heart surgery and 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. Open heart surgery basically means you're going to get access directly to the mitral valve in order to repair it. The mitral valve is inside the heart. So in order to do open heart surgery you need to divert all the blood from the patient to a machine. The heart is stopped so that you do the repair. 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 and greater than 97 percent of dogs being alive by discharge. Another reason why this is potentially exciting is that in the future it can be done by multiple centres. We have the privilege of pioneering it. Doing a procedure for the first time had its challenges, but we were able to work through it- mostly because of the amazing team that we have at Colorado State. And we are currently doing one or two cases per week, but we're also very involved with training other centres. All of the veterinarians on these centres first came to Colorado State University to see the procedure and learn about it, and then we have traveled to those centres to help them start their program. We currently have six active centres, and we have plans to open at least two or three more in the U.S and more centres in Europe and one in South America. We've been to the UK, we've been to Paris, we've been to Milan. Illinois is starting a program, VCA West Los Angeles, Tufts has started a program. We have plans to go to Brazil and two more programs in France are interested in starting programs. We are very committed to training other centres and making sure that they benefit from the things that we've learned about doing this procedure. And so one of the very appealing things about this will be availability and safety. Given that there are approximately 7 million dogs in the U.S alone with with degenerative mitral valve disease, we need a lot of more centres. And the other thing I would say about this procedure is how quickly dogs recover. I've truly been amazed. Dogs have walked outside the same day as the procedure, it is truly minimally invasive. 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. 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. 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. What we would predict is that dog will die of something other than heart disease. The oldest dog that we've done I believe is 14. We do not have a limit on age for this procedure so long as they look relatively healthy otherwise. There is a size range: the clamp comes in three different sizes. We prefer 4 kilos to 12 kilos. The smallest dog we've done so far is actually 2.8 kilos, so we're trying to help most dogs.
[Dr. Lopez]: So for patient selection...
[Dr. Orton]: our current preference is what's called B2, which is: they have criteria for remodeling ,their heart is a certain size, they typically have what we would characterize as severe leak -which generally means that when the heart pumps 50 percent of the blood is going forward out the aorta and 50 percent is going backwards- so they have severe leak, they either have not gone into heart failure yet (we like that) or they've recently gone into heart failure. And certain breeds of dogs like Cavaliers which get this disease a lot- we actually recommend that the procedure be performed at the B2 stage rather than after they've gone in the heart failure. We have done end-stage dogs. We would prefer to intervene sooner. Early in our experience, we did a Cavalier that was clearly a stage D; that dog is alive over a year later and probably would not have been alive more than another few weeks. We do not currently consider this procedure experimental. The procedure is done under guidance of trans-esophageal echocardiography; we also use fluoroscopy. One of the remarkable things that we see when we apply the clip -- the heart rate immediately falls and the blood pressure goes up because the leak has been reduced.
[Dr. Lopez]: Their heart has to work so hard because it has all this extra work due to this massive leak inside of it, and then all of a sudden this procedure stops the leak and the heart can just take a break...and rest...and not have to beat so fast.
[Dr. Orton]: That's what it feels like.
[Dr. Lopez]: I think at that moment in the video- it's a silent video- I honestly cried when I watched those videos. I couldn't believe it! I was just like: "THISIS AMAZING!!"
[Dr. Orton]: If it continues on the pathway that it's on this is going to be a very important advance in the field of Veterinary Cardiology this will become standard of care at some point.
[Dr. Lopez]: The new procedure is called "transcatheter edge to edge mitral valve repair." What should we call it?
[Dr. Orton]: You can call it TEER: T-E-E-R. You can call it an "edge to edge." The device is called "v-clamp," and that's what a lot of people call it:the v-clamp procedure .
[Dr. Lopez]: If people are interested in learning more, or potentially signing up to get this done, what are the steps that they should take?
[Dr. Orton]: Especially if you're going to consider a procedure like this, it starts with evaluation and ongoing management by a cardiologist. We need a cardiologist in the loop before, and we need a cardiologist in the loop afterwards.
[Dr. Lopez]: Cool. This is awesome! That was a really good overview of this new procedure.
[Dr. Orton]: Thank you for inviting me. Thank you for being interested in this. 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 centres going.
[Dr. Lopez]: That's amazing! Well I just want to say thank you so much for taking the time to share all this amazing information with us. And also thank you for all of the amazing things that you've done for pets with heart problems over the last few decades. You've helped so many pets, and you've completely helped to revolutionize the entire field. We're just incredibly grateful to you.
[Dr. Orton]: Well thank you... I'm not sure I'm worthy, but thank you. I'm just a veterinary surgeon with an interest in cardiology and trying to help animals with heart disease.
[Dr. Lopez]: I think I actually forgot when I first gave you your intro to mention that you were my professor when I was a vet student. Just trying to pass your course, like everyone else.
[Dr. Orton]: Yeah I go back a bit, I'm not going to say how long I've been there.
[Dr. Lopez]: That's okay, that's what Google is for.
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3 BEST PIECES OF ADVICE FROM THE EMERGENCY VET THAT COULD SAVE YOUR PET'S LIFE
1) DON'T WAIT TOO LONG TO GET HELP! If you wait too long, it could be too late. This is especially true for concerns such as laboured breathing, pale gums and weakness. You know your pet best, so if you are worried or concerned, "when in doubt, check it out!"
2) PREVENT THE PREVENTABLE. Learn as much as possible about dangers that face your pet, such as household poisons, seemingly harmless objects (like toys, clothing, garbage and rocks), other animals, and vehicles. Pets are like toddlers and they need a responsible adult/babysitter to protect them from danger. Puppies and kittens need to start their vaccines at ~8 WEEKS (and they need boosters too!) to protect them from deadly diseases.
3) BE PREPARED FOR THE WORST CASE SCENARIO. Have a plan in place, know your nearest emergency clinic, have the ASPCA phone number on speed dial. Know basic first aid training and CPR. But MOST IMPORTANTLY, BE FINANCIALLY PREPARED. The cost of medical treatment in an emergency, and the owners' ability to pay for it, is probably the most important factor that determines whether a pet will receive the medical care it needs. The best way to protect yourself is to have good medical insurance for your pet. Do your research.
**REMEMBER**: WE ARE ALL ON THE SAME TEAM, with the best interest of the patient as everyone's first priority. Let your vet do what he/she does best, and don't try to grab the steering wheel and obstruct your vet from doing his/her job. We are all in the same car, we are all headed to the same place, but only one of us has the driver's license (meaning, only the vet has the medical training and background to "drive the car").
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