He has degenerative mitral valve disease (MMVD) and has experienced several episodes of…

Hello, I am looking for veterinary advice regarding my 16-year-old male Yorkshire Terrier. He has degenerative mitral valve disease (MMVD) and has experienced several episodes of severe pulmonary edema since early September 2026. Unfortunately, intensive diuretic treatment has also been associated with a significant deterioration in his kidney values. He is regularly monitored by a veterinary cardiologist, but despite treatment, pulmonary edema keeps recurring. I would really appreciate a second opinion on his current treatment, the possible reasons for these sudden episodes, and any additional options that could help support both his heart and kidneys. ## 1. Cardiac history and echocardiography His heart condition had been relatively stable for approximately 1.5 years before the first severe episode in September. An echocardiogram performed on February 13, 2026, showed: - Diagnosis: Degenerative mitral valve disease, ACVIM stage B2 at that time - LA/Ao ratio: 1.54 - Normalized left ventricular internal diameter (LVIDDn): 1.42 - Left ventricular internal diameter in diastole: 2.27 cm - Left ventricular internal diameter in systole: 1.31 cm - Ejection fraction (EF): 75% - Fractional shortening (FS): 42% - Moderate left atrial enlargement - Mitral regurgitation with a narrow regurgitant jet - Flail anterior mitral leaflet - Preserved systolic function - No documented systolic or diastolic dysfunction - Sinus rhythm At his most recent cardiology examination on October 14, the cardiologist stated that the echocardiographic findings were still very similar to those from February, with only minor changes in cardiac dimensions. She was surprised by the severity and frequency of his pulmonary edema episodes despite the relatively limited progression seen on echocardiography. I do not yet have the exact measurements from the October examination. ## 2. Timeline of pulmonary edema and treatment **Early September – first severe pulmonary edema episode** He developed severe pulmonary edema and required intensive furosemide treatment. The initially administered doses were insufficient, and the diuretic treatment had to be intensified considerably. Eventually, the pulmonary edema resolved, but his kidney values subsequently deteriorated. **September 11** A follow-up lung ultrasound showed only a few isolated B-lines. His sleeping respiratory rate was still approximately 35–45 breaths per minute. **September 22** His condition improved significantly. His sleeping respiratory rate decreased to approximately 15–24 breaths per minute. He became more active, resumed walking and appeared much more comfortable. A lung ultrasound described the lungs as dry, without pleural or pericardial effusion. **September 23–29 – kidney deterioration** Blood tests showed severe azotemia, increased phosphorus and low potassium. Fluid therapy was recommended to support kidney function. **Late September – October 6** He initially received intravenous fluids, including approximately 160 ml on one occasion. Daily subcutaneous lactated Ringer's solution was subsequently prescribed at 125–150 ml per day. Because I was concerned about his heart disease, I actually administered approximately 100–120 ml daily for about one week. The last subcutaneous infusion was given on October 6. His kidney values improved considerably during this period. **October 9** His respiratory rate suddenly increased again. Lung ultrasound showed renewed signs of pulmonary congestion. Additional furosemide injections were required. **October 10** His breathing improved considerably, and the follow-up ultrasound showed only isolated B-lines. **October 11–12** He again developed increased respiratory effort, restlessness and difficulty sleeping. On October 11, he received two additional intravenous doses of 10 mg furosemide, according to my records. On October 12, lung ultrasound showed several B-lines on the right side, while the left side appeared considerably better. His regular oral furosemide was increased to 10 mg three times daily. **October 14 – another severe pulmonary edema episode** At approximately 2 AM, he developed another very severe episode of pulmonary edema. His respiratory rate reached approximately 80 breaths per minute at rest. He was coughing, very restless, unable to settle comfortably and had difficulty lying down and sleeping. Additional subcutaneous furosemide was administered as emergency treatment. I estimate that the total subcutaneous dose during that night was slightly over 30 mg. He was examined by his cardiologist later that day. The cardiologist decided to replace his regular oral furosemide with torasemide. Following the change, his respiratory rate gradually decreased from approximately 80 to 44 and then to around 36 breaths per minute while calmly awake. Today is much more better. His appetite and general behavior improved, and he became interested in his surroundings again. Because of the