Marla McAlpine never expected to be flying her dog to France for heart surgery, but that was what she found herself doing in March after her black and tan Cavalier King Charles Spaniel, Bentley, was discovered to have mitral valve disease with severe regurgitation. McAlpine was shocked. She had been told previously that Bentley had a heart murmur, but it was her understanding that it was nothing to worry about. Last November, at a veterinary visit for an unrelated problem, she was informed that her dog had a grade 4 heart murmur and should be seen by a cardiologist. She took the 7.5-year-old dog to Mikaela Mueller, DVM, a board-certified cardiologist who practices at Seattle Veterinary Specialists in Kirkland, Wash. Dr. Mueller told McAlpine that her dog would probably die of congestive heart failure in one to two years. “I asked if there was a surgery to fix him,” said McAlpine, who lives in Maple Valley, Wash. “Dr. Mueller said that she knew the Japanese had perfected a surgery, but the quarantine to take him over there would be months.” Owner Pushes Forward McAlpine wasn’t giving up. As soon as she got home, she started searching the internet for more information about the surgery in Japan. That led her to a website for the Clinique Veterinaire Bozon in Versailles, France. She discovered that the Japanese veterinary surgeon, Masami Uechi, DVM, traveled to France on a regular basis to perform the surgery in partnership with Dr. Jean-Hugues Bozon, who is learning the technique himself, and Dr. Sabine Bozon, a veterinary cardiologist who handles the dogs’ cases, from selecting which ones will be good surgical candidates to managing their recovery afterward. On the French clinic’s website, McAlpine found a post from another American, Nate Estes of Newbury Park, Calif., who had just returned from taking his Maltese, Zoey, for the procedure. She contacted him by email, asking to speak to him further about his experience. “He gave me his phone number, and we spoke for almost two hours,” McAlpine said. “I found out everything I needed to know about the surgery. After speaking with Nate, I knew that I was going to go to France to save Bentley’s life.” The Road Toward a Life-Saver McAlpine is among a gradually increasing trickle of American pet owners who are willing to spend tens of thousands of dollars to fly their beloved dogs to France or Japan for the life-saving surgery. They find out about it on the internet or, occasionally, from their cardiologists, who have heard of the procedure or have had another client take a dog for it. Social media has also helped to spread the word. Two Facebook pages are devoted to the surgery. One is a support group for people who have had or are planning to have their dogs undergo the surgery at the Bozon clinic in France. It was founded by Kimberly Valentine, whose dog Sparky Pluggs had the surgery last year. The Mighty Hearts MVD Community, whose founders include Nate Estes and McAlpine, is also a support group with the added goal of raising awareness of surgical intervention and eventually bringing it to the United States. McAlpine adopted Bentley when he was 2 years old, after he was given up by a family who had little interest in him. “I was determined to give this sweet boy a good life,” she said. “I loved him, and when he was diagnosed with MVD, I was going to do whatever it took to give him the best life possible.” On February 21, McAlpine got good news. Bentley’s surgery was scheduled for March 23. After that, the most difficult part of waiting was trying to keep her dog healthy enough to make it to France. She describes it as an emotional roller coaster. Just a week before their departure, Bentley’s breathing was labored and he was panting. A trip to the emergency room brought the unwelcome news that he was now in the early stages of congestive heart failure. “It was so scary,” McAlpine said. “He was put on Lasix and within 12 hours was doing so much better. France couldn’t come quickly enough.” Finally, they were on the 12-hour Seattle-to-Paris flight, with a connection in San Francisco. Accompanying Bentley and McAlpine were McAlpine’s mother, Patsy Hawley, nicknamed “Glammie,” as well as Mueller. She was so intrigued by the procedure that she asked if she could go along and observe. Bentley turned out to be a good traveler. McAlpine documented the trip on Facebook, posting “People on the plane were amazed at how good he was. He didn’t make a peep.” Bentley’s Outcome Bentley was one of a group of four dogs scheduled that week. Sadly, a fifth dog died just days before leaving for France, so McAlpine’s fears that Bentley might not make it weren’t unwarranted. The other dogs were Lola, Zeus and Belisa. During the surgery, which takes seven-plus hours, McAlpine went to a nearby restaurant with Glammie and Belisa’s owners, Tomas and Martina. Mueller texted photos of the procedure every 15 minutes. Bentley had complications and required chest compressions to get his heart started again. Then he was extremely slow to regain consciousness. “I’m feeling uneasy,” McAlpine posted on Facebook as friends and upcoming surgical clients waited anxiously to hear how he had done. Ultimately, all four dogs had successful repairs. Pancreatitis is a common postsurgical complication, and Bentley did not escape it, but unlike most dogs prior to the March surgeries, he and the other dogs didn’t develop any blood clots. They were the first group to receive stem cell treatments after surgery, with the hope of reducing inflammation and other complications. Now back home, Bentley’s one-month checkup with Mueller showed that his heart size and level of regurgitation had returned to normal. He can now expect to live a normal lifespan. McAlpine hopes that more veterinarians become aware of the surgery. “I believe it’s important for veterinarians to at least let pet owners know that there is a surgery out there to help prolong dogs’ lives,” she said. “Pet owners deserve to know that there is another option than to watch your dog die from congestive heart failure. It is not a cheap surgery, but we deserve to know the option exists and make the decision ourselves instead of waiting for fate to take our dogs.” How MVR Works Approximately 700 dogs have undergone mitral valve repair surgery in the nearly 12 years since Uechi developed the open-heart procedure. It’s now available at his JASMINE (Japan Animal Specialty Medical Institute) Veterinary Cardiovascular Medical Center in Yokohama, Japan; the Animal Recovery Veterinary Referral Centre in Singapore; and the Clinique Veterinaire Bozon in Versailles, France. It has a 90 percent success rate, depending on the dog’s age, heart status and overall health at the time of surgery. A dog who undergoes surgery can be expected to then live a normal lifespan. The repair surgery is complex and is described in detail at mightyheartsproject.org/intervention. It consists of a circumferential mitral annuloplasty to tighten the mitral ring and decrease or end mitral regurgitation. Usually, four to six chordae tendineae are replaced with expanded PTFE. Replacing the chordae is the most difficult part of the surgery, said Dr. Sabine Bozon. The heart is stopped, with a cardiopulmonary bypass machine providing life support. Other technology enabling the surgery includes two anesthetic machines, one of which provides assisted ventilation; a surgical table that can be tilted in any direction; various analyzers and monitors; and customized catheters, tubing and other equipment. The procedure requires a team of 11: Dr. Uechi and Dr. Jean-Hugues Bozon, who acts as assistant surgeon and is training to do the procedure on his own; three sterile instrumentalists; three nonsterile assistants; one perfusionist; one anesthetist-resuscitator; and one cardiologist sonographer. Potential postoperative complications include pancreatitis and thrombosis. While still an experimental treatment, IV infusions of mesenchymal stem cells on the second (and sometimes fifth) day after surgery show promise in reducing the inflammation that can contribute to those conditions. At the time of publication, only two groups of dogs had received this treatment as an adjunct to surgery. Next year, Dr. Sabine Bozon expects to publish a paper on the use of stem cells in this context. In an abstract presented in October 2016 to the American College of Veterinary Surgeons, Dr. Uechi writes: “The grade of cardiac murmur was significantly reduced to 0/6–3/6 three months postoperatively, and the heart shadow was reduced in the chest X-rays. Echocardiography confirmed the marked reduction in mitral regurgitant ratio and the left atrial dimensions. Mitral valve repair reduced enlarged cardiac size by reduction of regurgitant rate.” Although several U.S. veterinary schools have attempted to start similar surgical programs or to develop other surgical fixes such as a mitral valve replacement, they have so far been unsuccessful. Dr. Sabine Bozon attributes Dr. Uechi’s success to years of experience in performing the surgery and anticipating and dealing with complications. The experience of the surgical team and the custom equipment are factors as well, she said. The cost of the surgery in France is $40,000, which includes flying in Dr. Uechi and his surgical team. Additional expenses include preliminary lab work, airfare, lodging and follow-up exams once the dog returns home. Taking a dog to Japan costs approximately half that, but a seven-month waiting period before the dog can enter the country makes it a less desirable option for dogs who have already gone into heart failure.
