May 27, 2024

#122: We're Fixing Mitral Valves Now?! Everything You Need To Know About the Transcatheter Edge-to-Edge Repair Procedure. With Dr Brad Gavaghan and Dr Fiona Meyers

#122: We're Fixing Mitral Valves Now?! Everything You Need To Know About the Transcatheter Edge-to-Edge Repair Procedure. With Dr Brad Gavaghan and Dr Fiona Meyers
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Season 1

You know that conversation that you have with your client when you first diagnose congestive heart failure in their mitral valve disease dog? The one where you say: 'This will be the thing that kills your pet.' Well, that conversation is changing. 
Veterinary cardiologists  Dr Brad Gavaghan and Dr Fiona Meyers  introduce us to TEER (Transcatheter Edge-to-Edge Repair), a minimally invasive procedure that can completely change the outcome for your mitral valve patients. 
In this episode they explain how it works, what the procedure involves, and what the risks are. They also guide us through selecting the right patients for this procedure so you don't miss the window of opportunity, and outline a new approach for screening and monitoring your newly diagnosed heart murmur patients now that the paradigm of care has shifted. We get into the practicalities of referring your patients, including setting expectations and cost of the procedure. 

 

This episode is from our RACE approve clinical podcast series. Join our Vet Vault Nerds at vvn.supercast.com for more updates, refreshers, pro tips, and show note with over 450 episodes in Small Animal Medicine, Surgery and Emergency and Critical Care.

Serious surgeons, interns, residents and membership candidates should check out our new Advanced Surgery Podcast for a deep level of foundational surgery content.

 

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My conversation when I see a patient that comes in for the first bout of congestive heart failure, I will say to people, yeah, we're going to manage this.We're going to buy your animal healthy time, but it's going to be the thing that's going to kill it.Does this change that conversation?Absolutely.
My introduction for this one is going to be brief because you know the story.You get that dog in front of you with a heart murmur, and it's starting to go into congestive heart failure, and you know that this is probably the beginning of the end for that patient.Yeah, you're going to manage it, and you're going to keep it happy for months, maybe a couple of years if things go really well.
But we all know where this ends.Until now.There are some amazing things happening in the world of veterinary cardiology.And I don't want to spoil the whole episode by telling you too much about the tear procedure right now.Although we've kind of given away the end in the title there, haven't we?But you do need to know the details and you definitely want to hear about the how because it's paradigm shifting and it's so freaking cool.
So before you can sign your next congestive heart failure dog to the soon to be deceased pile, have a listen to this and share it with a colleague who might not know about it yet.Now a quick caveat on this one.This is obviously not a how to do the tier procedure in your practice episode.There is a way that you can learn to do it that's really actually quite straightforward with the right amount of time.
You go and you specialize in veterinary cardiology and then you work for a number of years, maybe 5 or 10 years as a cardiologist and you learn to do interventional cardiology and you do a few hundred of those procedures and hey presto, you ready to do the tier procedure.
So that is obviously my silly way of saying that this is one of those don't try this at home folks procedures that requires a lot of skill and experience to perform safely.Now, if that sounds self-evident, well, Doctor Fiona told me that she has recently heard of a few non specialist facilities who are offering tear procedures, which she says terrifies her because, quote, animals are going to die.
So enjoy this episode.Learn from it so that you can have intelligent conversations with your clients and then refer them to somebody who knows how to do it.All right, let's introduce our guests.Doctor Brad Gavigan and Dr. Fiona Myers are both cardiologists from the aptly named Veteran Cardiologist Australia right here in Brisbane.
And they are the first ones to perform the tier procedure in Australia together with their colleague, Doctor Chris Lamb.So we're privileged to have them share their knowledge with us on this topic.OK, that's it for my introduction.Enjoy.Doctor Brad Gavigan, Dr. Fiona Myers, thank you so, so much for joining us on The Vet Vault to talk about a very exciting topic.
Thank you.Thanks for having us.So I was thrilled the other day I was scrolling the social media, I don't know where I saw it, but something popped up that you guys are fixing mitral valves.There's a procedure that we finally fixing mitral valves.And I immediately got an e-mail and said please can we talk about this 'cause we need to know more about it.
So please tell us more about what's it called Tier TEER, right?Yeah, that's right.Transcatheter edge to edge repair.So it's absolutely a a game changer as far as getting the cardiology is concerned because as you know, mixomodous mitral valve disease is absolutely the most common disease that we see in our patients.
And for some of those patients it will become a life limiting disease process.MMM Ultimately that mechanical dysfunction in the valve is one which we haven't been able to effectively address except by Doctor Yuechi, the Japanese surgeon who has been offering open heart surgery by cardio pulmonary bypass.
Now, he's really the only surgeon globally who has had any success in mitral valve repair.And of course, in human patients, mitral valve repair is the gold standard, but for for a number of reasons, it is technically challenging in small animals and unavailable as well.
So this procedure, this transcatheter edge to edge repair is genuinely a game changer, which allows a reparative technique to be performed on patients who otherwise wouldn't have access or wouldn't be eligible to have a more descend of corrective.That's so cool.So, so can you talk me through the the basics of what the procedure looks like?
I'm obviously not gonna this is not a podcast to teach you how to do the procedure, but just to give us a bit of an overview of what you're doing.Yeah, I guess the procedure starts really with choosing the right candidate.Like a lot of procedures, the procedure has to match the patient and in this case, we're looking at B2 or C patients.
So the B twos are patients that have an enlarged heart, but not yet in heart failure.So typically they'll be on Pima Benden, the stage C we prefer probably ones that have early congestive heart failure, not cases that have where the heart is being damaged over a very long period of time because they obviously still have to get through a procedure.
So once we select the patient and there's the V clamp is looks a little bit like two sort of corporal stripes, I guess 2V's and those V's.Ultimately we have to have AV above the valve and AV below the valve.
And you pull those together and it works like a clip and just like a paper clip over the valve.And so the part of the valve that is the most dysfunctional and leaking becomes held in place and that markedly reduces the leak.And so to get to that point, the first thing would be to have the dog in theater.
It's a hybrid procedure.So there is a little bit of surgery involved.Most of our procedures that we do are all done via a vein or an artery, whereas this one's a little bit different.So we'd have the patient in right lateral recumbency and perform a small incision that lines up over the apex of the left ventricle.
And so that incision might be 5 or 6 centimeters in length.And then we localize the very tip of the heart and using a combination of transesophageal 3D ultrasound and fluoroscopic guidance, we pass the catheter through the very tip of the apex of the left ventricle.
And that catheter carries the clip.And to enter the heart, we put a purse string suture in.And the heart is surprisingly robust.So during placement of the purse string and even, you know, been a cardiologist for a couple of decades and I must admit, both myself and Fiona find it very exciting, you know, that we have that sort of access to the heart in a very Safeway.
And so we put a purse string suture in, put the catheter in through there and then place the device under guidance and we can move the device around to the optimum site.So with the 3D ultrasound, we can look at where the device is and then adjust it accordingly until we attenuate the majority of the mitral valve leak that's occurring.
And then we place the device, detach it, pull the catheter out and cut off the purse string and went on.Wow, that's very cool.So are you working endoscopically your initial like your chest wall incision?So first of all, it is an intrathoracic procedure.
So you've got, you're obviously ventilating and stuff like you're losing pressure in the thoracic cavity as soon as you go in, right?Yeah, yeah, absolutely.So it's remarkably non surgical for for cardiologists where we're doing interventional cardiology, which is exactly that non surgical cardiology, you know where we as Brad said, we access all of our all of our other procedures are done via peripheral vessels.
So we end up placed sutures and it it felt initially like this would be something that that is quite different.But the reality of it is it's a very small incision in the chest wall directly over the apex.There's no packing lungs out of the way or anything like that.With the more extensive throw economy, you literally exposing the epicardium exactly where you want to stick the catheter and then the rest is just done using fluoroscopic guidance and transesophageal 3 dimensional.
So by putting in what looks like an endoscope down the esophagus, but actually has an ultrasound probe on the end of it, we're able to image in three dimensions the heart, much like you see those 3D echoes of hearts and babies that people have during pregnancy, exactly the same sort of technology, but we're looking at the heart through the esophagus from above.
And, and so we can then see the device in the way that it's deployed really accurately.So none of it is US directly visualizing the mitral valve, I mean a surgical way, it's all indirect.And so for that reason, you know, that's why there is such reduced post operative morbidity and mortality rate is is trivial with this procedure.
And for that very reason and.Then when you so when you're actually entering the heart, you said you go in through the ventricular wall and is it just a catheter that goes in or do you actually cut the height?Like do you is it or does the thing?Does the device just pop itself in there?Yeah.So it's it's replace purse string suture in Apicardium and then in the centre of that purse string suture, we progressively insert an 18 gauge needle with a guide wire and then replace that along the guide wire with a large 14 French introducer that has a flange on the end.
And so then you have access essentially it's a big straw going to the apex, but the purse string allows you to, to prevent any bleeding around the straw around the catheter.And then the device itself is collapsible.So it's like an umbrella type device.So when it's collapsed, you insert it through the catheter and when it pops out the end of the catheter in the right place, then it then it forms its paper clip shape so that you can then grasp the valve and and pull it back into its paper clip formation.
What, what are they the VS made of?The thing that stays in there, is it a yeah, what?What's the material that it's made of?Yeah, it's a, it's a medical grade metal and then it's covered.It's got little barbs on it.So it's pretty aggressive.It grips on.But then it also has a a material aspect to it as well, which is facilitates endothelialization and and anchoring it in place beyond the actual mechanical anchor that's created with the biological response to it will help seal it in place.
Wow so I'm trying to picture what it actually does to the valve.So my and then correct me if it's a wrong understanding but I've always visualized the an old rotten mitral valve as bumpy like it becomes.I always explain to clients instead of a nice smooth valve that shuts you have lumps and bumps and it's all deformed and that's why it leaves gaps in between.
So does this thing go over that and squish that or just creates a smooth surface?Or how does it actually fix the leak?Yeah, so probably the best way to think of it is the valve, Instead of it being like 2 doors closing, it's like 2 doors that keeps swinging inwards and prolapsing and allowing blood to go past the edges of the valve.
And so if we put a clip like this across the valve, basically it has the doors stopped where they're supposed to stop.And so it prevents that door swinging the wrong way, basically.And there's a similar device called a Mitra clip that's been used in people now for about 15 years.
And there's over 150,000 people have had a Mitra clip in the canine world.It's probably worldwide.There's probably been 90 or 100 dogs have this procedure.The number one person doing it in the world is Doctor Chris Orton in Colorado.
And he's helped develop the technique.And, you know, he's published a paper where he looked at 40 dogs and 38 of those dogs had procedural success where the leak was markedly resolved.And the other two of the 40, it didn't die intraoperatively.
It was more just so difficulty in placing the procedure.So there's yet to be any published deaths using this technique that will come over time.Obviously with time comes the outliers and you know, that will happen.But I think the criteria for success is you would you would certainly want to be a cardiologist first.
And then the second is have a lot of experience at other cardiac interventions so that you know, your way around the heart.It's certainly, we'd consider it a challenging procedure, but but very doable.You know, it's literally described as a safe procedure now because of the amount that have been done success.
OK.But it's going to remain the the domain of specialists, right.It's not in 10 years time we're not going to be doing tier procedures in GP practice when the equipment gets better.I don't know absolutely this is this is this is absolutely a, a very fine skill set.
Like I said, it's very doable, but the background skill set that's necessary to get to the point where it's doable as extensive, yes, Brett, it's not just even being a cardiologist, it's having a heavy interventional caseload and familiarity makes it an achievable procedure in that regard.It's much like in human medicine, I guess.
You know, in human medicine, you don't just become a cardiologist, you become an electrophysiological cardiologist or surgical cardiologist or a pediatric cardiologist.And this is one of these subgroups of cardiology.Not all cardiologists will do this procedure and there's good reason for that.You know that it is.
It is a very fine-tuned skill set that does require you to have had a really heavy interventional background for it to be a successful procedure.I'm going to interrupt you for a second to tell you about a couple of things that's new with the Vet Vault and then we'll get straight back to our episode with Doctor Fyodor and Doctor Brad.
Now, I had a conversation with somebody I know fairly well and who is an avid listener of the podcast, who when I asked her about, do you listen to the subscriber only clinical podcasts, she said, oh, I didn't know that you had a separate clinical stream.And I was like, if you listen to the podcasts, how have you not heard the ads?
I feel like I go on and on and on about it.Clearly not enough.So just to be clear again, we have separate clinical subscriber only podcast where I speak to specialists about all of my questions and all of the protips and what's new and what you need to review about clinical practice exactly like this one that you're going to listen to right now.
In fact, this one is taken from the clinical stream.The difference is that we have more than 500 episodes in small animal medicine, surgery and emergency and critical care, including awesome show notes that you can refer back to on a searchable database, which has become an entire reference library.
And it's zone, right?So if you enjoy the clinical episodes you listen to on here on the free podcast, I want to guarantee that you're gonna love what we have for you on the subscriber space.Go and check it out now at vvn.supercast.com.That's VVN for vetweltnetwork.supercast.com.
I'll put the link for you in the show description.Then we have a brand new, this is exciting news, a brand new advanced surgery podcast that is separate to the other three, which we have made to be a guide for anybody who is doing a surgical internship, residency, surgical memberships, or any practicing veterinarian who is serious about this surgery.
The goal of this podcast is to give you a deep core fundamental understanding of what you do in surgery.So it's not a practical how to cut guide.It is a understand what you're doing and understand best practices for better outcomes and to make you a better surgeon.I'll put the links to all of these in the show description that's right there on your phone while you're listening.
Now if you scroll through all the text there, they'll be that you can click that will take you to our GP level continuing education podcast, which by the way, are now race approved, so you can get CE points for them as well.And to a cut above, which is the name of the Advanced Surgery podcast.OK, Back to Doctor Vienna and Doctor Brad and fixing heart valves.
Yeah.And is this the only repairing or fixing of the mitral valve that we do in veterinary science?I was, I was aware and I actually never followed up of the Royal College doing something to mitral valves as well.Is this what they're doing, or is there a different procedure out there as well?Yeah, there's there's two procedures.
So there's this procedure which involves not stopping the heart, not putting the patient on pump and then there's the mitral valve repair.So Doctor Ichi in Japan has pioneered an open heart approach and the that procedure is there's attempts to all around the world to try and reproduce his work.
And he's a very generous and active teacher, so he goes around the world, including Sydney University, looking to do that procedure and hand on that skill set as best he can.And I guess one of the issues is that it is very difficult for other surgeons to reproduce his success rate.
So most of the success rate with that procedure involves him doing it or being a part of the procedure.And that procedure certainly carry significant risk because of the pump having a 4 kilogram dogs heart circulation be artificially pumped around is, you know, that's a technique that in the humans has been going since the 50s to refine it.
Whereas in veterinary world it's it's a very complex procedure and has significant mortality and morbidity with that procedure.So, so two procedures, one is open heart and this is I guess we want a better expression of closed heart procedure and the open heart procedure can deal with some more advanced mitral valve pathology.
So there's some cases that are not suitable for AV clamp or a tier operation, but can have the open heart surgery.So they're not complete replacements for each other, but very different procedures.Okay, so that sounds like that's not something that's going to be available to to most of us to refer for an open heart valve replacement.
What about the tear?You guys are the only ones in Australia doing it at the moment, is that correct?Yeah, yeah.And and probably for the foreseeable future we will be because it does require multiple cardiologists to have the sort of success that we're going to keep aiming for.
You know, for this particular procedure, there was myself, Brad and our cardiologist Chris Lamb who was working the transesophageal 3 dimensional echo.So it really is, it's absolutely A2 hands on the device procedure and then another cardiologist doing the imaging.
And so really for it to be anything less and that there'll be corner cutting.And so because of the just the gross lack of cardiologists in Australia, I I think that it will be probably a long time before it will be offered to the same level of success anywhere else.
OK.And what about for international listeners?What's the availability like elsewhere?Yeah, Well, certainly it's becoming more other cardiology facilities, particularly in North America who have cardiologists who currently do a high interventional caseload, such as Texas, Colorado, North Carolina, places which have already got a very established interventional caseload are now adopting the procedure.
So Texas A&M have got a long history of interventional cardiac success and they've they started doing these procedures actually the same week as us.So it will become more available in North America.And as Brad said, doctor Chris Ortner, Colorado is, he's not a, he's a cardiology surgeon.
So the training is actually specialty surgery, but he's certainly the most globally known cardiac surgeon in the veterinary industry.And, and he's really pioneered this technique because probably born out of his own frustration with the lack of success with open heart repair.
And so he's really driven the success of this or developed this device and adapted it from humans to veterinary patients.So Colorado have had the highest caseload go through their doors so far.But it, it is a, it will be something which is far more, more available globally as other interventional cardiologists take this up.
But the the long term results are something of course that we don't yet have on and and that'll become clear over the next few years.But we're certainly very optimistic about its role in veterinary cardiology at the moment.What about the UK and Europe?Is anybody doing it there yet?
I I I would be very surprised if the facilities in the UK which already do interventional cardiology aren't looking at this procedure and they haven't already started enrolling patients.I suspect they will be offered soon.OK.
Very skilled interventionalists in Germany and France and in Spain.And so I would suspect that a bit like we are in Australia at the moment, there's cardiac groups that are just beginning to start doing this procedure.Yeah, we know there's groups in South Korea and other Asian countries that are looking to commence it as well.
All right, So in terms of us at GP level having conversations with clients about it and selecting the right patients.So you said already it's going to be B2 or C.So the N this this physical changes to the heart.So basically when I hear that, when I do my vaccination and I hear that murmur and the dog has a scan and they go, Yep, there's a mitral changes, but no chamber enlargement yet, That's not my candidate.
There's no benefit of getting in ahead of the game and saying, well, like, why not do it?The sooner the better.That's a really good question here.So B1 mitral valve disease, you know, those dogs, a significant portion of them are going to live to be little old dogs and die from a different disease.You know, so stage B1 dogs are not the ones that stand from this procedure.
With regards stage B2 versus C dogs, there is a a bit of a crossover there because of course once a patient has developed congestion and they are a stage C dog, then we know they have a finite life expectancy.Now those patients have 6 to 12 months to live and so an interventional procedure which can structurally correct the valve is potentially life saving for those patients.
But some of those patients will have a valve morphology which is no longer amenable to transcatheter edge to edge repair.Whereas dogs with stage B2 disease who have very advanced cardiac remodelling, who have not yet developed congestive heart failure, those patients, you know, we're starting to sense that those patients probably have a higher frequency of valve morphology which is amenable to the technique.
So having said that, we're not looking at early stage B2 patients even because B2 can be a stage of disease for which a patient can be in for several years.So we don't want to do the procedure on a patient who isn't looking down the barrel of a bad prognosis.
You know, we, we want to do it on a patient who has foreseeable life shortening as a result of their heart disease where this procedure will will change that prognosis for them.And so advanced B2 dogs and stage C dogs with the correct Valvul mythology of the the patients who stand to benefit from this procedure.
OK, so there's almost like a the little Goldilocks period where the animal has proven that yes, this is going to be a problem for me, but it's not that far advanced where you go.Well, things are pretty ruined in there.You can't go for.Yeah, Yeah.That's, that's what Chris Horton and our experience has been, is that the more we look at these valves, it it, it seems to be a mode that there's value in sort of looking at them earlier and being proactive rather than reactionary.
OK, so for us as GP bits planning this, let's say I have the, you know, I know my patient has a murmur, it has much well disease and now it's on the radar that there is potentially a fix down the line.Do we say to our clients, we'll come in for us or go to your cardiologist or somebody for a six monthly scan?
And when we hit that stage, when we go, OK, crap, now we've started getting chamber enlargement rather than saying, well, let's wait until you start seeing signs of congestive heart failure and then saying, OK, well, now go see Brad and Fiona.Well, how have we planned this?Are we?Let's say my dog gets sick.
How am I going to stop it from dying of heart failure?We have a lot of inquiries from Interstate veterinarians and our advice to them is to have a cardiologist, if the first scan was not done by a cardiologist, certainly have the next one done by a cardiologist that we'll work with that cardiologist in terms of discussing what information we need from the views.
Because the routine exam, even biocardiologists won't necessarily cover what we require in terms of understanding mitral valve morphology for patient selection.So we will send them a list of criteria and then they can send the images to us and and then we start to narrow down the process of whether that patient is a suitable candidate.
So if you said cardiologist, that includes, let's say I had a medicine person scan my dog that you said still not because find a cardiologist that you guys will work with.Let's say I'm in Perth, go see a cardiologist there and they'll chat to you guys and you'll say to them here's the scans I need.
That's the views, that's what we're looking at and to get all the right info.Does that make sense?Yeah, because what we don't want is the patient coming from Perth or Adelaide and then we assess them on site just for the day before the procedure and find something unexpected and so, you know, a cardiologist said he has to be involved in the process.
OK.In terms of setting expectations for us as the the primary caring vets, my conversation when we started, I think you alluded to it earlier, but when I see a patient that comes in for the first bout of congestive heart failure and you go, OK, I will say to people, yeah, we're going to manage this.
We're going to buy your, your animal healthy time.But it's going to be the thing that's going to kill it probably unless something tragic happens in the next six months.Does this change that conversation potentially?And you said we don't know the long term outcomes, but does it mean that you can actually change the conversation?
So, well, there's something I can do to fix it.Absolutely.And I think for these patients there's not any ambiguity that this clip significantly reduces the leak in the martial valve.You know, the little patient that we did just recently went from being in heart failure to discontinuing diuretics the day of the procedure.
You know the.Day of the procedure.The day of the procedure and the mitral murmur disappeared, you know, because what the clip does is it not just seals together the valve, but it draws the annulus into a smaller dimension as well.So even though the valve itself is raggedy and nasty, it seals better in a smaller heart, you know, so there's no ambiguity that the procedure itself is very effective at reducing the leak in the mitral valve.
What, what we don't know yet is how that translates to long term outcome, right?If we're talking purely about mitral regurgitation, wow, it's, it's amazing, you know, but but what we don't have in a very scientific way is data yet that says that these dogs do live longer as a result of this, you know, because although it's something that we, you know, we, we don't anticipate that the, and there's no case reports even of the clip coming loose and creating death by a different means.
You know, we don't have that data yet.So we're we're very optimistic in that we can see the mechanical response to the devices extraordinary.But how that translates in a clinical patient, which is something a scientist needs to be very cognizant of, that we don't yet have the data to support the translation to survival times.
So what's the the longest living patient that do you like the Colorado team?How long have people been doing this procedure for?Well, it's been going in Colorado now for three years, three years in human patients.And that's probably the best way to answer that question is to look to the human field, because in human patients, the gold standard for mitral valve insufficiency is cardio pulmonary bypass and open heart repair.
But of course, there are a whole bunch of humans who aren't eligible for cardio pulmonary bypass because of comorbid conditions.And so for those humans amongst us who can't have definitive mitral valve repair under cardio pulmonary bypass, they've been having for the last 18 years a Mitra clip, which is this device in humans.
And in people it, it has well and truly been established that the mitral creates an extension in survival time above medical therapy alone.So while we don't have the data in dogs, we do have the data in people.And people are absolutely at an advantage by having the structural repair for the valve via mitral clip as opposed to just medical therapy.
So everything is looking very, very much like we'll have that same data in dogs.Wow.The practical aspects in Australia, obviously cost is always a discussion we have to have.I won't ask you for direct pricing, but like compared to a TPLO or another big surgery or something, this is obviously a very specialized procedure.
How viable is it for your average client price wise?Yeah, I think there's a couple of parts to the question.Firstly, because it's an acquired disease, insurance is a big player in this and we know that the experience already with the first case that we've done is the insurance company are absolutely involved in helping out with the cost.
So I think that will be a big help.The open heart procedures will range from 50 to 70,000.This procedure will range from 30 to 35,000 in the average patients.So there does seem to be no shortage of people being enthusiastic for it.
But obviously, you know, there's, there's also going to be a group of people like that is, is going to be beyond what is is reasonable for this circumstance.And yeah, we'll, you know, our goal is to absolutely provide the very best medical care for those patients.And then for other clients that are interested in this procedure, then, you know, this obviously becomes a viable alternative.
Yeah.I mean, in terms of if you get a because you do get the dogs that at a relatively early age, 8-9 years old start developing congestive heart failure.If you go well, that's potentially going to give them years extra then it's it sounds very pretty sensible.I don't think it's doable.
Absolutely without sounding like a sounds person, this is this is something I would absolutely do in my own for my own dog.How?Many cabbies are you going to?Are you guys going to start seeing?We already see a lot of cabbies, unfortunately.I'm I'm just what you said about insurance.
I wonder if there'll be a cavalier kick child's exclusion.You cannot get a tear done for your cami.All right, well, what am I missing out on?Because I, to me, this was just, I just wanted to do an introduction, basically get the message out there that this thing exists.And there is another, as I said, the it's really, I love stuff like this where the conversation I've been having with clients for 20 years suddenly changes in any field of veterinary medicine.
And this sounds like one of those pivotal moments.Yeah.And I think for us as cardiologists, you could have heard a pin drop in the room when the clip was placed and we put the colour Doppler on.And to be honest, it was very close to no mitral flow.And and for the heart murmur to go from grade 5 to no murmur on the same day.
And the heart physically during the operation, we can measure it shrinking down and getting smaller.So that happens within a matter of minutes.Blood pressure changes, cardiac output changes.So for us, this is a career changing procedure, you know, and that we've spent, you know, between 30 to 40 years telling the same story to people.
And now we have, we have a different narrative.And Doctor Chris Orton, who's been the leader in a cardiothoracic surgery for the last three decades, you know, this is now he's, it's almost his legacy because he's gone from the trials and tribulations and late nights of hoping his heart patients would survive cardio pulmonary bypass to now he does one or two of these per week.
You know, this is this is being transformative for him and for us.And, and I think obviously for general practitioners too, it's nice for them to have a different story and the procedure and the the sort of question and answer that go along with procedure.
All of this is on our website.So clients and vets have portals there where they can click on and read about it and that'll probably answer the majority of their questions.And then, you know, we're really only an e-mail away to answer any other questions.I just, I'm amazed that what you said, you can literally see the chamber shrinking while you're doing it.
So, so that's not a permanent stretch chamber enlargement and congestive heart failure.It's, is it almost like an over inflated balloon and you let a bit of air out, then it shrinks back down again.I I always assume that once that atrium is big and flabby, it's big and flabby for life.I love this stuff you you could get me started on this pathos and I could go forever.
But essentially, you know, we talk about the heart dilating and that's just too crude a terminology to use.It's a very active process, reactionary process to the human dynamic changes.And this is happening in reverse, you know, so the heart is very actively certainly there's an initial reduction in the regurgitate volume, which allows the heart to become smaller immediately and the heart very proactively remodels.
And that's the the wonderful thing about this procedure that while the clip is reducing the size of the leak, it's also, as I said, reducing the size of the annulus.So the valve continues to age, but it just fits better in a smaller heart.So it seals better, It works better as well, despite the clip.
So it is, it is truly an extraordinary response to to what is a very significant change in the dog's heart.Jeez, I love what you're saying Brad about for you for you guys, because I as you were saying that it because you've you've spent your entire career quieting this thing and just palliating really and getting better and better at palliating.
And now this is major leap where you go, well, finally we can freaking do something about it and not just fight around the edges.Almost.What a what a paradigm shift for you.It's amazing.Yeah.And clients have, you know, been for decades saying, because people are obviously aware that, you know, a lot of people have a relative that's had valve repair and sometimes this exact valve.
And, you know, for literally decades had to say, actually, no, we don't don't have a procedure.So that's really changed the conversation for us.And yeah, so it's a, it's a exciting time to be a cardiologist at the moment.How big were the high fives once you got your gloves off after surgery when you did your.
Yeah, I think, I think we kind of look at each other and just thought, wow, this is, this is so doable.And you know, procedurally we felt very comfortable with it as well.While it was challenging, I think we've come along at a very good time where 150,000 people have had the devices being developed over that time.
And then it's been further developed for our veterinary patients and then someone like Doctor Chris Orton who's taken this on and collaborated with the device engineers and manufacturers.So we feel like we've come along at exactly the right time, sort of after the first, well, the 2nd publication has come out to show that this is a safe procedure.
So it's certainly, it's a procedure that, you know, if, if doctor Chris Orton was asked if it's experimentally, he's almost a bit bristly because it's certainly not, you know, it's a, it's a routine procedure now for cardiologists that are interventional cardiologists and have a skill set in this area.
There's potential for this to be just something that we do every month, and you know that that's our plan.OK wow.Is there anything I'm not asking?No, I think you probably covered everything.Well, everything that we can we think of to ask.But yeah, I think absolutely when you hear a murmur and a dog, the first thing should always be let's find out what it is because then we can know whether or not we need to worry about it or not and and how to deal with it moving forward.
So identification of a murmur should always just be a question then of what's creating the murmur.And then we can answer all the questions that come from that once we've had a a diagnostic echocardiogram.And so those patients, then they'll be LED down the pathway, which will be optimized for them.And if it turns out that murmur that was picked up, you know, three years ago, it was mitral valve disease, then we'll be seeing that dog back for it's recheck and it's recheck and it's recheck.
And then if they look like they're at risk for congestive heart failure and there are candidates for this procedure, they'll be well positioned to have a procedure performed and, and find the optimal pathway forward for that patient.So I think, I think that's that's really the take home message, I guess for general practitioners is when you hear a memoir, let's know what that memory is 1st.
And once we know, know what it is, then the path will become clear for that patient.And if this is what's involved for that animal, then we'll know about it.Yeah, this adds a different level of motivation for being on top of exactly what's happening.Because it can.As a GP practitioner, your heart cases could feel almost hopeless to the extent where you go, oh, it's got a murmur, let's see what happens.
Yep, now it's got heart failure.There's some prism, it's getting worse, there's some, you know, without referring it for a cardiologist work up to sort of manage it medically based on clinical science, it can be tempting to do that.But with this, there's a very good reason to say, OK, This is why we need to know exactly what's happening to your patients because we have this potential fix and we don't want to miss our window of opportunity.
Yeah, absolutely.I think, you know, that's always true because even there'll be some little, you know, we're betting people will say that most small breed aged dogs with a left eye because systolic mammal will happen with some spatial valve disease and that's the safe bet.But you know, some of them won't.Some of them will have an age 7 of PDA that's never been picked up before and that too is a curable disease, you know, but we need to not just treat with frusamide, we need to know what the underlying problem is.
And so the optimal path will always be to get a definitive ISIS and and then we can know whether or not fruismite is all that's necessary for a patient or whether or not there is an option for a transcatheter edge to edge repair or a PDA occlusion or pulmonic stenosis balloon procedure or if there's something better than just palliation once a patient becomes symptomatic.
OK Brad, Fiona, I can't wait to get this out there to the rest of the red world and I can't wait to send.I'm my first patient to do for this.I'm going to be looking out for the right patients from now on.So thank you so much for sharing this with us and for taking the time to talk to us and for doing the work to getting this out to Australia.
That's amazing, thank you.Before you disappear, I wanted to tell you about our new weekly newsletter.I speak to so many interesting people and learn so many new things while making the podcast, so I thought I'd create a little summary each week of the stuff that stood out for me.
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Dr Brad Gavaghan

Dr Fiona Meyers