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DMVD (possible CHF) in elderly Maltese

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  • DMVD (possible CHF) in elderly Maltese

    Forgive the long post. I’m hoping for some advice regarding degenerative mitral valve disease in a 12 year old Maltese (he will be 13 on October 26th). Everyone says this, but this dog is my heart. I am beside myself with the turn he’s taken the last few months.

    In August 2018 I took him to his longtime vet in Texas for a general wellness exam, vaccinations, and a health certificate. We were gearing up for a move to Virginia at the end of August. I had noticed some coughing with exertion and his vet called it collapsing trachea. I asked about any heart murmurs (that’s the first thing that pops when you Google “dog cough”.) No murmur was detected and he was pronounced healthy and ready to travel.

    In March 2019 he started having loose stools that led to bloody diarrhea within a week. I made him an appointment with a local vet (I’m new to Virginia, so all vets this year are new to us.) I brought a stool sample. This new vet did not look at the stool sample, promptly had one of the techs take it outside to trash it, listened to his heart and said he had a grade 4 heart murmur and needed a cardiology consult. When I asked again about the bloody diarrhea, she suggested Purina FortiFlora (a probiotic to sprinkle on his food). I asked her recommendation for dog foods and she strongly recommended Royal Canin. I returned home discouraged and now very worried and booked the cardiology appointment.

    In the meantime, the FortiFlora didn’t seem to be working as the stools were still very loose with spotting of blood. I started researching dog foods. Enzo had been eating Blue Buffalo Small Breed his entire life. After researching foods, I settled on Nulo FreeStyle Senior (the Royal Canin she suggested did not have good reviews). After the switch, his stools firmed up and he was less arthritic-appearing. (Note both the BB and the Nulo are grain-free foods and I started reading everything I could find on heart disease in dogs between the March appointment and his cardio appointment set for June.)

    June 2019 he had a consult, bloodwork, and echocardiogram with a cardiologist at CVCA in Leesburg, VA. He was diagnosed with Grade 4 heart murmur, moderate degenerative mitral valve disease, severe left atrial enlargement, severe mitral valve regurgitation, moderate left ventricular enlargement, and mild pulmonary hypertension. His coughing was again diagnosed as collapsing trachea. Enzo’s blood chemistry profile was totally normal and he was started on 3.25mg pimobendan, 5mg enalapril daily. 20mg tablets of lasix were prescribed to have on hand for symptoms of CHF (including coughing or labored breathing.) The cardiologist and her tech both suggested although this was not the DCM related to a grain-free diet, Enzo should be eating a high-quality grain-inclusive diet like Royal Canin or Purina Pro Plan. They also suggested a dental to remove his teeth and decrease bacterial load on his heart.

    I started Enzo on the medications and scheduled the dental for July 8. The dentist recommended was also out of the Life Center in Leesburg (ADOS). $4k later, he had all teeth extracted. One of the pain medications they started him on was Gabapentin and he seemed to have a severe reaction to this in that he could not walk. He was staggering and falling down, his breathing was difficult, he would stop breathing for seconds at a time and would only start if I gave a brisk sternal rub. I called the vet very concerned and they just said to stop the Gabapentin and they would make a note in his chart.

    After the less-than-satisfactory first appointment with the local vet, I established care with a different local vet for follow-up blood work. All blood work after starting the new heart meds came back normal and no adjustments were made to dosing schedule. Enzo was recommended to see cardiology for a 6month follow-up in December 2018. At this other local vet, I asked again for dog food recommendations. He strongly recommended Royal Canin. Third strong recommendation from a Vet sounded promising to me.

    After he had recovered from his dental, I made the switch to Royal Canin. I switched him very slowly, but as soon as he was on half Nulo and half Royal Canin, the loose stools started again. I thought his system would eventually even out, so I stuck with it. From July to September I fed Royal Canin and he had loose stools (ranging from soft to diarrhea) the entire time.

    August 2019 he had his annual wellness and vaccination appointment with the local vet. I mentioned his stools were very loose on the Royal Canin and if there was another food he could recommend. He insisted the RC was the best of the best and had no suggestions for firming the stools.

    At the beginning of September I had had enough of the diarrhea and switched Enzo back to Nulo FreeStyle. Immediate firm stools.

    September 4th Enzo had his first seizure. I had just arrived home from work. He was excited and coughing, but the coughing turned to hacking, and he sank to the floor and started paddling, lost control of his bowels. The entire episode took only 20 seconds. There was no pre or post-ictal stage. He came out of it fairly normal. I took him to the emergency vet in town and they took chest x-rays. The ER vet said his heart wasn’t particularly enlarged and there was no fluid on his lungs. He said most of the time when senior dogs seize, it’s due to a brain tumor. I asked about the coughing and what I thought was lack of oxygen. He said the coughing didn’t sound like it was heart related, but his trachea was also open on the radiograph, so he really didn’t know. Enzo’s pulse ox was 95 and he was released. I called the cardiologist and they didn’t want to see him back so soon. Simply suggested to wait for it to happen again and then see neurology.

  • Original Poster

    September 26th Enzo had his second seizure after getting out of bed for a drink of water at 2am. Same preceding events with the coughing and hacking and sinking to the floor. Another call to cardio in the morning and they suggested neurology.

    I called Neurology and set up an appointment for October 14th.

    September 28th I returned from the grocery store to a happy excited coughing dog, who started gasping for breath and sank to the floor for his third seizure. The coughing persisted after he came out of the seizure so I started him on the lasix. He is still coughing.

    I called the cardiologist again this AM. I called cardiology again and they said to just take him to neurology (even though I feel it’s his heart and/or the medications and I had to start him on lasix). When I called on the 26th I asked that they at least leave a message with the cardiologist asking about possible lack of oxygen from the heart condition (syncope vs seizure) or possible side effects from the pimobendan (two of the side effects are coughing and seizures). When I asked the receptionist about the message last week and that I hadn’t heard back she said “oh yeah, she said it’s highly unlikely it’s the medication and there was no need to call you back.”

    So now I am reaching out the COTH for help and advice. Find a new cardiologist? Keep neurology appointment? Continue on with the medications? The dog was asymptomatic up until he started the medications. He had a murmur detected after a trip to the vet for bloody stools and the longtime cough was diagnosed as collapsing trachea by multiple vets. How do I know if this is heart related or otherwise?


    • #3
      Oh man, I'm so sorry. Do you have a vet you trust back in Texas? Can you send the records back there for a review? It sounds like there's been little holistic guidance for you...the specialists do their thing and sign off but no one is bringing it all together. Finding that relationship after a move is SO HARD I'm in the same boat but my old vet has been willing to do record reviews and chat via phone and it's been such a huge help.

      Wrt the food, if Royal Canin isn't working, get him on what does. I lost a cat to a Royal Canin recall issue...its not perfect, and if it's not agreeing with him, there's no reason to stick with it.

      I hope you're able to find some answers and some cohesion to his care. Best of luck, keep us posted.


      • #4
        We have a yorkie mix with many of the same symptoms you describe. I feel very fortunate to have a great vet, and vet practice, where we can have discussions - questions and answers, back and forth - about her care. I think I'd start by looking for a "primary care provider" who takes the time to listen and explain things, and who can refer you to specialists with a similar approach. I'm sorry your frustration seems to be related to the providers as much as the condition.

        Fwiw, ours is on pimobendan/vetmedin and lasix at doses higher than you describe. Her coughing is stable (it happens, but only a few times/day) and the lasix is a real pain but it does seem to help. She gets it twice a day. She has had goopy poop forever and gets colitis every couple months - she is a sensitive flower, somewhat sensitive to food but more to the state of her environment. She has had a couple of small seizures, maybe, but none since we started the heart meds. We haven't gone as far as a cardiology consult but are working by clinical signs and response to the meds.

        I wish you the best in figuring this out. There has to be a really good small animal vet someplace in Virginia!


        • #5
          I'm not a vet or a doctor, but am a cardiac sonographer.

          It doesn't sound cardiac to me. Loose bowels during an episode does not sound like syncope, it sounds like a seizure. Possibly mini-strokes? But you probably would have noticed some neurological symptoms after that many episodes if that was the case. It would be very, very unlikely for MR to cause a seizure. If the heart function was severely decreased you could have thrombus throwing small clots, but again, unlikely based on the time frame.

          I would keep the neurology appt. The coughing is tricky. Some of it could be his heart (severe MR results in CHF and coughing in humans too, especially dependant on position), some could be the collapsing trachea. I would continue with the meds for now.

          Honestly, I would just feed whatever your dog seems to be doing best on.

          P.S. Unfortunately it sounds to me like your vet in Texas missed the murmur. Sudden onset mitral valve disease is very uncommon in dogs. Degenerative disease takes time. Your dog has likely had a "murmur" for several years.


          • Original Poster

            Thank you for the responses thus far. The cardiologist had her receptionist call back and said I was to go to the ER immediately to stabilize him today. He’s not unstable though. Respiration and heart rate are normal for him. He’s sleeping next to me. The last thing I want to do is stress him out with a trip to yet a different vet. I want him to see cardiology again to reassess the heart and medications. When cardiology refused to see him I asked for a recommendation for a second opinion and the receptionist said they don’t recommend other cardiologists. This is beyond frustrating. I called his regular vet who agreed not to take him to the ER if he is calm. We agreed I would try to find another cardiologist and keep the neurology appointment.

            Simkie I wish I had a vet to send records to for review. I’m not sure I trust the general vet in Texas enough for a second opinion. Especially since I suspect, as GoodTimes suggested, he likely missed a heart murmur back in August 2018.

            GoodTimes you referenced “MR” a few times. What is MR?


            • #7
              LEL oops! Sorry “MR” is mitral regurgitation.


              • #8
                Internet vetting here- could be syncopal vs neuro absolutely. Get a video of it to show neuro.

                Has he had collapsing trachea diagnosed on rads?

                I see coughing with heart dz for 2 reasons- left atrial enlargement pushing on the airways- tends to be unresponsive to cough meds because of the mechanical component. Fluid will cause coughing that's generally responsive to lasix.

                Collapsing trachea that is severe sucks because not many meds do much anyway. I always tell ppl if there are lots of treatment options it's because none work well.1

                I'd keep appt with neuro just to cover all the bases.

                Discuss with your primary doc getting him on some cough suppressants or even trying cerenia for the trachea. Calming meds may help too if hes having seizures or syncopal episodes due to excitement or stress


                • #9
                  Has anyone eventually done a parasite check; bowel and heartworm. Seems an oversight
                  -- * > hoopoe
                  Procrastinate NOW
                  Introverted Since 1957


                  • Original Poster

                    Horrific update: Enzo had a second cardiology opinion today. He is in end stage heart failure. Severe left atrial enlargement that has progressed rapidly from June. They added Spironolactone and Lasix to his regimen. She suggested he has approximately 3 months. I am devastated.

                    He had an “episode” while we were with the cardiologist. She had just finished his echocardiogram. She diagnosed it at a syncopal event. She said he’s just not getting enough oxygen.

                    She adjusted some of his medications. The initial cardiologist had his weight wrong. They said he was 6kg. He’s only 5kg. His blood pressure today was very low, so she cut his enalapril in half. The pimobendan was adjusted to a lower dose as well.

                    I asked this cardiologist if the pimobendan at a high dose early in the DMVD caused the rapid progression. She said it only causes rapid progression if given too early. How do they know what is too early? I feel he has progressed so rapidly the last three and a half months. I’m wondering if the first cardiologist prescribing too much too soon was the trigger for such a drastic downturn.

                    kmwines yes, collapsing trachea was diagnosed on rads. Most recent rads taken September 4th and reviewed by three different vets.
                    hoopoe yes, recent bowel and heartworm parasite check performed August 20. All clear.


                    • #11
                      Pimobendan is recommended as soon as there is heart enlargement noted on radiographs. There was a very large study called the EPIC study in which pimobendan was found to be the most protective heart med to start over enalapril and other meds.

                      I've never heard a cardiologist say anything about it causing progression. But I have not attended every cardiology lecture ever given so some may have had personal experiences.

                      There is also a very large dosing range for most of those medications so the difference in 1kg does not change dosing by much. The dose range for pimobendan for example is 0.25-0.35mg/kg with safety being higher than that.

                      This is the consensus statement from the american college of veterinary internal medicine (cardiologists are a subset of this specialty).



                      • Original Poster

                        kmwines he has been one 0.6mg/kg/day since the first echo in June. I’m assuming the 0.25-0.35mg/kg is q12h dosing? Chetboul and Lefebvre wrote an article outline of the comparative adverse effects of Pimo in dogs with mild DMVD. The argument was that due to its positive inotropic effect, it actually worsens mitral regurgitation and causes progression of heart enlargement.

                        I know this is just one study. There is one other I can’t locate right now. I’m grasping. Trying to figure out why this is moving so quickly when some dogs are able to live for years with CHF.


                        • #13
                          These are the 2 very large studies done with pimobendan


                          I am sorry your little guy has progressed so rapidly. It's so hard to see them getting worse quickly. Unfortunately there is not a good way to tell how or why things progress so differently in individual dogs. Starting on the meds that you did when you did follows all the recommendations.


                          • #14
                            I wouldn't really say things are moving quickly. Unfortunately it sounds like you just found out late in the game, partly from the Texas vet missing the murmur, and complicated by the collapsing trachea.

                            Like I said earlier, degenerative mitral valve disease doesn't progress quickly. Your dog has likely had a murmur for several years. At the first echo he sounds like he had CHF with preserved LV function. The coughing that you noticed over a year ago was probably due to CHF.
                            Keep in mind that CHF can be caused my a number of things, some more difficult to manage than others. Chronic severe mitral regurgitation with severe atrial enlargement doesn't have a good prognosis in dogs or humans. I doubt the medication dosage made much of a difference.

                            I know it's not the outcome you were hoping for, but you've done right by your dog. Enjoy the time you have left.


                            • #15
                              Yep...heart failure is notoriously silent and the onset insidious....sometimes until it is too late.

                              I lost my 13 1/2 y.o. beagle to right sided heart failure. I thought I noticed decreased exercise tolerance (and no other symptoms) but it was mid summer and old dogs lie around a lot in the air conditioned house. By the time I could for sure say, yes she has exercise intolerance it was early October. I took her to the vet and they were chasing around liver issues because she had mild-moderate ascites (fluid in the belly). By the end of the month she could not even walk past the neighbor’s house without wearing out. I started taking her with us (me and her brother) in a wheel barrow so she could go on walks too). I took her to a different vet who was also concerned with cancer or a liver disease when they did an ultrasound and echo and discovered the heart failure. By this time, she absolutely did not respond to any of the meds...enalapril or furosemide. Right sided heart failure is very hard to treat. Her ascites soon became marked and she looked like a football with legs. She often would lie on the bed and groan, clearly uncomfortable. I did the only thing I could which was give her a peaceful passing in November. Talk about a rapid decline.

                              I am am so sorry for predicament. Sometimes, CHF just doesn’t doesn’t respond well and as it gets more pronounced, is not able to be reversed.

                              Jingles to LEL and Enzo.