How We Discovered That Limoncello Had a Heart Issue

In the middle of the 2017 Dock Diving Season, Limoncello suddenly stopped jumping.   Brian was up on the dock with her at a competition in June 2017, and released her to jump.  Limoncello literally sauntered to the end of the dock and flat-jumped in. She continued to show disinterest at every event after that. We actually stopped jumping her for a little bit and took her to the vet for some testing. Nothing concerning was discovered at that point. She began to jump towards the end of the season again, and at the 2017 World Championship .… But still not showing the same interest and “extreme” tendencies she had before. At that point we resorted to the fact that perhaps she was just tired of a sport she once loved…just like so many German Shorthaired Pointers who are surrendered to rescue or are “dumped” by hunters because they just woke up and decided to stop hunting. Although we did not have an echocardiogram done at the time, there was medically no need to at that point… Cello did not display other symptoms, her bloodwork came back normal, and nothing irregular was heard by stethoscope.

Fast forward to February 2018.  One day in early February, Hooch started licking Cello’s chest as if it was coated in honey! He was exhibiting behaviors of an intact male (Hooch is intact, Limoncello is not) – but instead of being interested in her hind-end , he wouldn’t leave her CHEST alone … turning over on his back to lick her chest, nosing at her chest while whimpering, and did everything in his power to get to Cello if we tried to separate them.  Thinking her hair follicle issue had returned, and we were missing something like a rash or infection on her chest that was peaking Hooch’s interest … we took her back to our primary veterinarian, Dr. Helen Campbell .

This time, while I was sitting in the waiting room at Old York Veterinary Hospital, another dog entered the office waiting room with his owner.  Although Limoncello is extremely human-friendly, she despises most other dogs outside of her pack, and will act on her aggression.  Cello was freaking out at the other dog as the vet tech called us back into the room.  With Cello’s adrenaline still pumping, our veterinarian walked into the room.  She immediately listened to Cello’s heart with her stethoscope…and thought she heard a murmur.  However, as Cello began to calm down, the “noise” went away.  Jokingly I said to Dr. Campbell,  “Walk a dog by her again … that’s what she was freaking out about earlier.”  Surprisingly, she said,  “Yes – let’s do that!” One of the vet techs had their dog at work with them, so they leashed their pup and walked her by the exam room with the door left open.  Dr. Campbell had her stethoscope on Cello’s chest the entire time.   As Cello began to break out into what we call “Cujo mode” as she saw the dog pass by the doorway… bam! …the “noise” was back! 

Although we will never know the answer, we have two thoughts on the discovery of Cello’s heart murmur:

  1. This heart issue could have began to develop during the 2017 dock diving season (our answer to why her performance dropped).  It is likely it could have gone unnoticed because when Cello is at the vet she is usually super calm IF there is no other dog in the waiting room with us.  We usually time our visits so that Cello does not encounter other dogs in the office, so it’s quite possible she was not “excited” enough to display symptoms during other visits.  The murmur was undetectable while she was calm, so Dr. Campbell would not have heard the murmur with her stethoscope at other appointments.
  2. Cello’s 2017 performance was totally unrelated, and the heart murmur began in the beginning of March when  “Dr. Hooch” discovered it! 

Regardless of when the murmur began, it had to be explored to determine if there were any other related cardiac issues.   Dr. Campbell referred us to Dr. Bossbaly, a cardiologist at Veterinary Specialty and Emergency Center (VSEC).

 

Cardiology Consult and Dilated Cardiomyopathy Diagnosis

On March 19, 2018 we had a consult and echocardiogram appointment with Dr. Bossbaly, the cardiologist at VSEC. We honestly expected Dr. Bossbaly to confirm the heart murmur Dr. Campbell heard, and move on. However, what we left there with was a diagnosis we had no idea even existed.

Limoncello’s echocardiogram did in fact confirm a grade 2-out-of-6 heart murmur with leakage of the mitral and tricuspid valves, but also revealed that the dimensions and contractility of Cello’s heart was consistent with the early onset of Dilated Cardiomyopathy (DCM). Because Limoncello is an athlete, Dr. Bossbaly said that we would have to consider that some of these findings may be induced by her athleticism.

We were informed that the progression of dogs with occult DCM is difficult to predict. If and when clinical signs arise, symptoms that may be seen could include lethargy, exercise intolerance, difficulty breathing, or panting excessively. We were also told that at this time there was no reason to be concerned since Cello’s heart rate was normal and her lungs were clear.

It was suggested that we do a repeat echocardiogram in 5-6 months, or sooner if any observable cardiac symptoms surface. It was also recommended that we start Cello on several supplements, keeping an eye out for any signs of loose stool or diarrhea:

  1. L-Carnitine (1 gram twice daily)
  2. Taurine (1000mg twice daily)
  3. Coenzyme Q10 (30mg once daily)

We were instructed to record Limoncello’s sleeping respiratory rate (SRR), as this is a subtle indicator of changes. Increasing trends may suggest the development of congestive heart failure. Normal sleeping respiratory rates should be less than 30 breaths per minute. If Limoncello’s SSR and effort increases, it was to be reported to Dr. Bossbaly and Dr. Campbell immediately. To help us keep track of Cello’s SSR, we downloaded the Cardalis® app in the Apple Store. I believe this app is available for other devices as well.

It was suggested at this point that we retire Limoncello from dock diving to be on the safe side.

Dilated Cardiomyopathy Overview

The following is an article from Pet Health Network .

Overview
Heart disease is as scary in dogs as it is in humans. Dilated cardiomyopathy (DCM) is a serious condition of the heart that occurs when the heart muscle becomes diseased and weak. The heart is a muscular pump that pushes blood around the entire body. In the normal dog, it beats approximately 180,000 times a day! A muscle working that hard needs to be in shape, with good muscle tone, to do its job effectively. When DCM strikes it renders the heart muscle weak and flabby; therefore, the heart starts to fail at its job. 

 The heart has four chambers. Like many mechanical pumps, the heart has two functional parts. The atria, seen above as thin-walled chambers labeled “left atrium” and “right atrium,” act as pump primers. Blood returning to the heart is held here and when the atria are full, they contract, pushing blood into the pumping chambers or ventricles. When full, these pumping chambers contract forcefully, pushing blood out to all the blood vessels in the body.

You’ll see that the heart is actually made up of two pumps, a right and a left one, based on their anatomic position in the body. So we have one pump made up of the right atrium and right ventricle and one made up of the left atrium and left ventricle. Valves between the atrium and the ventricle ensure blood always moves in one direction, from the atrium into the ventricle.

When dilated cardiomyopathy strikes these chambers, all enlarge because the heart muscle becomes weak and stretched. Blood is still pumped, but not effectively. Limb muscles and organs within your dog’s bodies need a constant and consistent blood supply to work properly. Ineffective circulation will cause muscles to become weak and organs to malfunction. This will result in some of the symptoms we discuss next. Additional symptoms are caused because fluid will leak from the blood when it isn’t pumped effectively. As a consequence, we see abnormal fluid accumulations on top of muscle and organ dysfunction. That’s why swollen ankles are a common sign of heart problems in people. You won’t see swollen ankles in your dog, but your veterinarian might see fluid leaking into the lungs, which causes breathlessness and coughing.

Risk
Breeds commonly affected by DCM include:

Symptoms
Your dog’s body has some protective mechanisms that help him cope with poor heart function early in the disease, so symptoms may not be obvious at first. With time, the heart’s ability to function becomes so poor that these mechanisms can’t keep up and symptoms of failure are easier to spot. When your dog’s heart first starts to fail, the muscles in his legs don’t get the blood they need and your dog may not be able to play or exercise as vigorously as he used to. This will become progressively worse as the disease grows and the heart gets weaker. Over time, abnormal fluid buildup in the lungs will cause your dog to cough and seem out of breath. The coughing can become so severe that your dog may even cough up blood-tinged fluid.

Diagnosis/Treatment
Your veterinarian will typically recommend a number of tests to fully evaluate your dog’s heart, and the effect that poor circulation is having on the rest or his organs.

These could include:

  • A radiograph, commonly known as an x-ray
  • A blood test for a cardiac biomarker called NTproBNP 
  • A chemistry and CBC profile to assess the state of all the organs
  • A blood pressure test
  • An electrocardiograph (ECG) to record the electrical action in your dog’s heart
  • An echocardiogram (ECHO)

If your dog is diagnosed with dilated cardiomyopathy, your veterinarian may prescribe the following treatment:

  • Nutritional modification, such as a low-sodium diet or the addition of supplements, such as carnitine
  • Diuretics, which help to clear the excess fluid that results from poor circulation
  • Drugs that relax blood vessels, making it easier for the heart to do its job as a pump 
  • Drugs that help the heart muscle function more effectively, giving additional strength to the pump
  • Regular but controlled daily exercise, once symptoms have been controlled

Drugs that do several of these things at the same time are available.

This article is being shared from Pet Health Network. for the Original article link: Click HERE .

5-Month Check-Up

Almost immediately after diagnosis of Limoncello’s DCM, news regarding the grain-free diets being the culprit for many dogs’ cardiac issues exploded.

At this appointment with Cello’s cardiologist, Dr. Bossbaly, an echocardiogram was done. This time the test revealed that despite the fact that Limoncello was taking the suggested supplements and had displayed no symptoms whatsoever, her heart murmur increased in severity from a grade 2 to a grade 3, and her DCM had worsened. Although Cello’s heart rate was normal, her echocardiogram measurements of her heart’s left ventricle both in diastole (relaxation) and in systole (contraction) phases had increased, which confirmed progression of her heart disease. We were devastated.

Due to the new developments on the grain-free diets, it was highly suggested that change not only Limoncello’s diet, but the diet of our whole pack. Blood work was drawn and sent to UC Davis to determine Limoncello’s Taurine level. Results revealed that Cello had a low plasma Taurine level of 50. (Normal plasma range of Taurine in dogs is 60-120, and Normal Whole Blood range is 200-350).

We were told to increase Cello’s Taurine from 1,000mg twice daily to 1,500mg twice daily, and to keep her L-Carnitine and Coenzyme Q10 the same. A 5-month follow-up echocardiogram was also scheduled.

During the appointment I was provided with a handout with information about the study of grain-free diets. The following information is copied directly from Limoncello’s discharge paperwork, and is written by Dr. Lisa M. Freeman, a veterinary nutritionist and professor at Cummings School of Veterinary Medicine at Tufts University:

  1. Popular grain-free dog foods may be linked to heart disease. The common factor was a diet heavy in peas, lentils, chickpeas, and potatoes – the carbohydrates typically intended to replace the grains. Diets with exotic ingredients such as kangaroo, duck, fava beans, buffalo, tapioca, salmon, lamb, barley, bison, and venison and even some vegan diets have been associated. DCM has now even been seen in dogs eating raw or home-prepared diets.
  2. There is ongoing suspicion that the disease is associated with these boutique or grain-free diets, with some of dogs improving when their diets changed. The US Food and Drug Administration (FDA) Center for Veterinary Medicine and veterinary cardiologists are currently investigating this issue.
  3. Exotic ingredients are on the rise. Exotic ingredients are more difficult to use. Not only are the more exotic ingredients unnecessary, they also require the manufacturer to have more nutritional expertise to be nutritious and healthy. Exotic ingredients have different nutritional profiles and different digestibility than typical ingredients, and also have the potential to affect metabolism of other nutrients. For example, the bioavailability and metabolism of Taurine is different in a lamb-based diet compared to a chicken-based diet or can be affected by the amount and types of fiber in the diet.
  4. Dr. Freeman believes pet owners are feeding these exotic ingredients because they’re falling victim to marketing which portrays exotic ingredients as more natural or healthier than typical ingredients. There is no truth to this marketing, and there is no evidence that these ingredients are any more natural or healthier than more typical ingredients. This is just good marketing that preys on the desire of pet owners to do the best for their pets.
  5. There is no proof that grain- free is better. Many pet owners have unfortunately also bought into the grain-free myth. The fact is that food allergies are very uncommon, so there’s no benefit of feeding pet foods containing exotic ingredients. And while grains have been accused on the Internet of causing nearly every disease known to dogs, grains do not contribute to any health problems and are used in pet food as a nutritious sources of protein, vitamins, and minerals.
  6. Consider your dog’s diet. If you’re feeding boutique, grain-free, or an exotic ingredient diet, reassess whether you can change to a diet with more typical ingredients made by a company with a long track record of producing a good quality diet. Stop reading the ingredient list. Although this is the most common way owners select their pet’s food, it is the least reliable way to do so. Be careful about currently available pet food rating websites that rank pet foods either on opinion or based on myths and subjective information. It is important to use more objective criteria such as research, nutritional expertise, and quality control in judging a pet food. The best way to select what is really the best food for your pet is to ensure the manufacturer has excellent nutritional expertise and rigorous quality control standards.
  7. If you are feeding your dog a boutique, grain-free, or exotic ingredient diet, watch for early signs of heart disease… Weakness, slowing down, less able to exercise, short of breath, coughing, or fainting. Your veterinarian will listen for a heart murmur or abnormal heart rhythm, may do additional tests, or send you to see a veterinary cardiologist for your dog to have x-rays, a blood test, electrocardiogram, or ultrasound of the heart (echocardiogram).
  8. If your dog is diagnosed with DCM and eating one of the diets discussed above, the following steps are recommended:
    • Ask your veterinarian to test whole blood and plasma taurine levels. The University of California Davis Amino Acid Laboratory is recommended.
    • Report to the FDA. This can be done either online or by telephone. The FDA may be able to help with testing costs for your dog. Reporting it will also help us identify and solve This current problem.
    • Change your dog’s diet to one made by a well-known reputable company and containing standard ingredients such as: chicken, beef, rice, corn, wheat. Changing to a raw or home-cooked diet will not protect your dog from this issue and may increase the risk for other nutritional deficiencies. If your dog requires a home-cooked diet, or has other medical conditions that require special considerations, be sure to talk to a veterinarian or a veterinary nutritionist before making a dietary change.
    • Start Taurine supplementation. Your veterinarian or veterinary cardiologist can recommend an appropriate dose for your dog. Be sure to use a brand of Taurine with good quality control.
    • Any improvements in your dogs DCM can take 3 to 6 months. Your dog will need regular monitoring and may require heart medications during this time. There is no guarantee that your dog will improve but it is certainly worth a try. Make sure your dog is getting the best combination of medications to treat for heart disease, as this can make a difference in the outcome.You can find a board certified veterinary cardiologist near you on this website: https://find.vetspecialists.com/

During this appointment, I was also given a handout from the FDA on how to report a pet food complaint.

Although I have different views on some of the dog food ingredients that were considered standard in Dr. Freeman’s above statements, our entire pack was immediately taken off their grain-free diet of Orijen brand kibble, and I began to research food companies. I also spoke to our primary veterinarian, Dr. Campbell about our pack’s individual nutritional needs. Lastly, I also spoke in great length to the owner of a local dog food supply store who has had relationships with several prestigious dog food companies and distributers for an extensive amount of time.

How to Report a Pet Food Complaint

The following handout was given to me at Limoncello’s 5-Month Check-Up appointment at VSEC with Dr. Bossbaly. You can also access the link directly by clicking HERE.

How to Report a Pet Food Complaint

Report a Pet Food Complaint

You can report complaints about a pet food product electronically through the Safety Reporting Portal or you can call your state’s FDA Consumer Complaint Coordinators.Your report to the FDA is important. Thank you for submitting it. The FDA continues to devote time, energy, and resources to monitor reports of illness that could be related to pet foods, to determine their root causes where possible. The FDA will review your report to determine whether any follow-up investigation is possible or needed based on the information provided. A follow-up investigation could include collecting pet food or treats, or seeking a diagnostic sample from your pet for analysis. Even if no testing of pet food products or diagnostic samples is needed, your report will be part of adverse event and product surveillance to help prevent future problems. You may choose to have your pet food product tested by a private laboratory, but testing may be costly. The FDA cannot pay for private laboratory testing costs or provide reimbursement for veterinary costs associated with your animal’s illness.

Please have as much of the following information available when submitting your complaint:

Consumers often transfer dry pet food into other containers for easier handling.  If possible, please save the original packaging until the pet food has been consumed.  The packaging contains IMPORTANT information often needed to identify the variety of pet food, the manufacturing plant, and the production date.

  • Exact name of the product and product description (as stated on the product label)
  • Type of container (e.g. box, bag, can, pouch, etc.)
  • Product intended to be refrigerated, frozen, or stored at room temperature
  • Lot number – This number is often hard to find and difficult to read.  It is stamped onto the product packaging and typically includes a combination of letters and numbers, and is always in close proximity to the best by/before or expiration date (if the product has a best by/before or expiration date).  The lot number is very important as it helps us determined the manufacturing plant as well as the production date.
  • Best by, best before or expiration date
  • UPC code (also known as the bar code)
  • Net weight
  • Purchase date and exact location where purchased.
  • Results of any laboratory testing performed on the pet food product
  • How the food was stored, prepared, and handled

Description of the problem with the product.  Examples include:

  • Foul odor, off color
  • Swollen can or pouch, leaking container
  • Foreign object found in the product.

If you think your pet has become sick or injured as a result of consuming a pet food product also provide information about your pet, including:

  • Species (dog, cat, rabbit, fish, bird, other)
  • Age, weight, breed, pregnant, spayed/neutered
  • Previous health status of pet
  • Any pre-existing conditions your pet has
  • Whether you give your pet any other foods, treats, dietary supplements or drugs
  • How much of the suspected product your pet normally consumes
  • How much of the “suspect” product was consumed from the package?
  • How much of the product you still have
  • Clinical signs exhibited by your pet (such as vomiting, diarrhea, lethargy)
  • How soon after consuming the product the clinical signs appeared
  • Your veterinarian’s contact information, diagnosis and medical records for your pet
  • Results of any diagnostic laboratory testing performed on your pet
  • How many pets consuming the product exhibited clinical symptoms
  • Whether any pets that consumed the product are not affected
  • Whether your pet spends time outdoors unsupervised
  • Why you suspect the pet food caused the illness

Cardiology Service Update: Dog Food & Dilated Cardiomyopathy

The following handout was forwarded to me by Limoncello’s cardiologist, Dr. Beth Bossbaly. The Direct link can be accessed by clicking HERE.

CARDIOLOGY SERVICE UPDATES: DOG FOOD & DILATED CARDIOMYOPATHY
The Cardiology Service has developed this document in response to the alerts from the FDA. These alerts identify an
associated risk for some grain-free diets containing certain ingredients (legumes like peas, pea components, lentils; white
potatoes, sweet potatoes) and a diagnosis of dilated cardiomyopathy (DCM). The links provided throughout this document
can be copied and pasted to obtain additional information.
FDA Alerts found here:
https://www.fda.gov/AnimalVeterinary/NewsEvents/CVMUpdates/ucm613305.htm
https://www.fda.gov/AnimalVeterinary/ResourcesforYou/AnimalHealthLiteracy/ucm616279.htm


What is Dilated Cardiomyopathy (DCM)?
DCM is a heart muscle disorder that results in a weak pump function and heart chamber enlargement. In the early stages of
this disease pets may appear totally healthy with no apparent clinical signs. Later in the course of this disease, dogs may
have a heart murmur, an arrhythmia (irregular heart beat), collapse episodes, weakness or tiredness with exercise, and even
trouble breathing from congestive heart failure. While there are some breeds of dogs (like Dobermans) that have a genetic
predisposition to development of DCM, there are also nutritional factors that may result in this disease.


What should I do?
If you are feeding a diet of concern based upon the FDA alert we recommend that you consult with your veterinarian or
veterinary cardiologist. We provide 4 general points for guidance below:

  1. An initial step is to consider whether you are willing or interested in performing additional testing to assess whether
    your pet is affected with DCM. If you believe your dog is at risk, showing any of the aforementioned clinical signs or would
    prefer to simply rule out any heart disease, we recommend that you first have your pet’s taurine levels tested (both whole
    blood and plasma levels) as well as seek an echocardiogram by a board-certified veterinary cardiologist. Low taurine levels
    are associated with development of DCM in dogs and are sometimes a component of this current issue.
    Information on taurine testing can be found here: https://www.vetmed.ucdavis.edu/labs/amino-acid-laboratory
  2. At this time, diet change is recommended when possible and should be considered regardless of the results obtained
    from any testing. You can consult with your veterinarian in selecting a new diet that avoids the ingredients of concern listed
    by the FDA. When selecting this diet, we recommend that you choose a diet that is manufactured with rigorous quality
    control measures and research behind the formulation. A way to ensure that your diet meets these recommendations is to
    follow the following guidelines that were generated by a large number of the world’s leading experts in veterinary nutrition.
    Food selection guidelines found here:
    https://www.wsava.org/WSAVA/media/Arpita-and-Emma-editorial/Selecting-the-Best-Food-for-your-Pet.pdf
  3. If your pet is identified through testing to have a low blood taurine level or evidence of DCM by echocardiogram, we urge
    you to report this information to the FDA.
    FDA reporting guidelines found here: https://www.fda.gov/AnimalVeterinary/SafetyHealth/ReportaProblem/ucm182403.htm
  4. Work with your veterinarian(s) to determine the best course of action and medical treatments if indicated. In the case of
    a DCM diagnosis, diet change alone may not be sufficient and additional medications may be prescribed.

Please continue to monitor the FDA website and the UC Davis School of Veterinary Medicine Newsfeeds for updates and
recommendations regarding this issue.

Secondary IDEXX Laboratory Taurine Test

On October 18, 2018 Limoncello had a check-up with our primary veterinarian, Dr. Helen Campbell at Old York Veterinary Hospital to have a Taurine test done. This time the test was performed through IDEXX Laboratory.

It has been two months since we had deleted all legumes from our pack’s diet, and switched them all to kibble that included good grains. It has also been two months that Cello had been on an increased supplemented amount of Taurine.

Limoncello’s Taurine plasma level had now risen from 50 to 216. This was high considering the normal plasma range is 60-120. However, when we consulted Cello’s cardiologist, Dr. Bossbaly, she suggested that we still keep Limoncello on all the same supplements and doses, including the 1,500mg of Taurine twice daily.

10 Months Into the DCM Diagnosis

As scheduled from Limoncello’s last echocardiogram, Limoncello had her next echocardiogram and cardiology exam with Dr. Bossbaly on January 15, 2019.

During this appointment, Limoncello’s heart disease slightly improved on the current supplements. However, her heart function still remained abnormal. At this point we were told to:

  1. continue the current supplements with no changes
  2. keep tracking Cello’s sleeping respiratory rate

An echocardiogram was scheduled in 6 months.

16 Months into the DCM Diagnosis

It has been 16 months since Limoncello was diagnosed with DCM, and 11 months since she has been on a kibble that includes an appropriate source of protein, goods grains, and is free of legumes. As scheduled at her last check-up with Dr. Bossbaly, Limoncello had a cardiology exam and echocardiogram on July 23, 2019.

As Limoncello was getting her echocardiogram, I waited in Dr. Bossbaly’s exam room praying she would return with news that Cello’s DCM had not worsened. When Dr. Bossbaly entered the room with a big smile, exclaiming, “YAY!” I was completely caught off guard, and confused! My nervous response was, “What do you mean?… Her DCM stayed the same and didn’t worsen…RIGHT?” What came out of Dr. Bossbaly’s mouth next made my own heart skip a beat… “Limoncello’s heart has completely corrected itself from DCM,” she said. “NO WAY!?” Was all I could manage to get out before I burst into tears of joy.

Dr. Bossbaly explained that Limoncello’s heart was back to normal both in size AND function. Cello did still have a murmur, but it downgraded from a 3 out of 6 to a 2 out of 6. Dr. Bossbaly lifted all exercise restrictions, and approved of Limoncello coming out of her dock diving retirement to compete again! After speaking with our primary veterinarian, Dr. Campbell, she agreed as well. HALLELUJAH!

We understand that we have been blessed with the fact that Limoncello’s heart has healed to the point of normal size and function. Unfortunately, not many dogs have been this lucky. Limoncello is a prime example of a dog diagnosed with DCM directly related to Taurine deficiency. We are beyond grateful that Limoncello made a complete turnaround with the implementation of a dietary change and proper supportive supplements.

Many people have asked us what food we suggest they switch their dogs to in order to get their pups off of a grain-free diet. Our suggestion is the same for everyone. All dogs are unique – and all dogs have different nutritional needs, just like humans. Take into consideration your dog’s health issues, daily activities, do some research on dog food companies, and consult the doctors you trust the most before making a decision on food. Keep in mind that not all dogs do well on all foods. It may take a bit of experimenting before you settle on appropriate food and supplement choices for your pup.