Kunjan Bhatt, MD, Austin Heart Cardiologist, Congestive Heart Failure Subspecialist, presents on the Left Ventricular Assist Device evaluation process and patient experience.
So, Ken John Madigan. Um, I'm a heart very specialist with Austin Heart. We're going inside my partner, Dr Morris and Dr Thomas, and it's a privilege to be here today. I appreciate you all and Molly, um, asking me to speak e thought that this lecture I had given previously for the in patient service line for hard player was very a proposed to what's happening both in the hospital. Also in our practice. And it really is. If we're considering a patient for advanced therapies, what do we do? Eso I've written here? So you want to get in l a vod the work up in the evaluation process and the patient experience, it really is more just the events therapy process. Azaz. There's a lot of overlap with transplant, um, housekeeping rules. Um, I really can't, um it's gonna be hard to this, um, her product todo q and A live. So when I would ask is perhaps through the chat. If you can send your questions and Alicia and Shell, you're here with me so they can certainly keep a list of questions. And if there's some time at the end of happy to answer them And of course, as you know, if you have questions and we don't get to them, just you can always text me or call me off line, and we can address them. Thank you. That being said, um, we have an epidemic of heart that I know we have a pandemic of Corona, but we have an epidemic of heart. It's been there. So you estimate the U. S population is 300 million Americans. Estimates of 2 to 3% of the population have heart failure. So we'll say 2.5 or 2.6% of about 6 to 7 million Americans have heart failure. And then the division of reduced the F versus preservative so ifs about 40%. S list some, um, So if you think of the preservative population, it's about half and and then by default than the other half hard reduced yet, Yeah, The patients that we really kind of consider advanced therapies for are those who have, as the name implies, advanced heart failure. And that's about 10 to 12% of that have ref population, and that roughly estimates to about 150 to 250,000 patients a lot of patients. That's not a small sum of patients. Problem is that if you look at transplants over time transplants being the gold standard therapy for decades the transplant volume is pretty small. These were pretty modest numbers. If you think of there's a 200,000 patients in need and only about 2 to 3000 patients getting advanced therapies reparable, uh, family transplant, the gap in therapy. And that's where we're kind of the event of the L VAD came in. To begin with, we have a big patient population, large wait times. A lot of patients don't do well and expired because they expire on the wait list. And so to really get patients better therapies, onda potentially advanced therapies for those who aren't eligible for transplant. That really was the the Gap, which the L vet has, as to some degree, met that unmet need for that unmet niche. So about 5000 patients who get Albats per year and we'll go over those numbers and in a few slides. So about 3 to 4, about 3000 with transplants about 5000 with bad, you know, doing the math that's still a big gap in therapy. It's estimated that about 16,000 patients with advanced Heart actually present to a hard player specialist s 0 200,000 patients with advanced hard for their 16,000. That's see, um, physicians like myself and Dr Thomas Um, So then there's still a large population patients that don't see us and don't get considered for advanced therapies. Humbling statistics. So elevate volumes over the last several years still pretty modest if you go back to 2014 to 2019. So the pumps have changed and the pump sieve arguably improved in quality. Um, the number of implants themselves have been pretty steady, and then the type of valve odds you may have you may have heard names like HeartMate two HeartMate three h Bad. Um, two companies kind of have the lion's share of the market. Abbott makes the heart made two and heart made three. Andi. Then Medtronic makes the heart Where, um, if you look at the bar graph, that is the heart made to on older pump that was really the workhorse for the late 2000 and 8 2009. Up until the mid 2000 and teens. Heart made three because of the moment inthe retrial really took off. And that's the this e guess this, but like Purple Color and that really from 2017 has essentially replaced the HeartMate two on drily, to some degree the heart, the H bad. So the heart made three. We do feel as a community is an excellent pump. It really has probably the best team of dynamic profile. And, interestingly, looking at the kinds of implants were doing, we are picking patients who are older and and in that realm, perhaps those patients are better suited not for transplant. Maybe not to get a VAT as a bridge to transplant that maybe they just get a destination therapy that Does that mean the pump is different? No, the pump is the same. The HeartMate DRI doesn't taste, look or smell any different in a patient who is a bridge to transplant. Destination therapy bad. It's just nomenclature that that destination therapy means as a standalone therapy. Richard transplant means that they deserve a heart transplant. If they could get one, we need to kind of get them there, and the bad kind of services that niche. So we get this question a lot. You know, when's the right time to refer to heart failure, specialist. And we always appreciate early referrals because when patients are referred early, you can start having those critical conversations about what is life like with advanced heart failure therapies. What is life like without article? That's her. I think. Like anyone else, patients deserve to have an informed discussion having an informed discussion when someone is in intensive care, such as someone we have right now on va ECMO. Um, it's hard to talk to them. They're too intubated. They're critically ill there, family members air flustered there. It's hard to make kind of informed decisions when things were crashing and burning. So here we have the Inter max, um, a scoring system of how critical is a advanced heart failure patients. So advanced heart failure Patient Intermix seven is kind of a placeholder, a patient who's a functional class three. We see him in clinic every 3 to 6 months, and they're doing okay there, kind of percolating along, and as your number goes down, so say inter max for, for example, that's a patient who has been admitted for D compensated heart failure. They're not on Anna tropes there on medical therapy, but perhaps they are starting to become the revolving door. They're starting to get admitted over and over again. Those are folks we definitely want to be seeing, if that's in fact, what the patients may consider. And with the referring teammate, Consider, but really the sweet spot for where we find, um, patients to get l've odds would be the Inter Max three and Inter Max three represents someone who presented the heart hospital or to Round Rock or Georgetown South Austin somewhere in our network, Um, who came in with reduced to have heart failure. Um, they needed a nine a trope because it was felt that they were Shockey and they're on a Tropic. Support seemed to help them, and we sometimes proved that they're undertook dependent either in the hospital or is now patient by winning the Latrobe and ensuring that they felt worse or they objectively did worse on some kind of a functional assessment. And then we put them back on the Latrobe, and we call them on a trip dependent because on the on a trip there, better off the undertook their worse. And some of that is the subject of some of this can be objective. But those air stable patients who then are on I V drip with a PIC line and their home, and we see those kinds of patients on a weekly basis. Those are the sort of folks I would almost think if you have a general surgeon taken out of gall bladder orthopedic surgeon operating on the knee, you don't want your general surgeon operating on the ball better when the gall better has perforated and the patients in septic shock. You don't want your orthopedic surgeon operating under knee when the patient's bed bound from such bad D. J d. So likewise, you don't want your heart failure surgeon to operate on your patient when they're crashing and burning on four drips intubated on va ECMO. You want them to go in electively on their own 2 ft with a pic line on a nine, a trope so that they have the biggest chance of success. And I know this is intuitive, but the sicker you are going in, the sicker you are coming out, the healthier you are going in. Uh, health care. You are coming out, and it's all about outcomes. And so as we start our little that program, um, in literally in a few weeks, which we're very excited about, we wanna be choosing patients who are in this risk category Interfax, threes and fours and not so much the ones. And choose as we know, the outcomes are not great. So when we look at our patients, we want to use our yardstick of what's our clinical gut. Tell us about this patient. How sick are they? But there's also some objective scoring system, and there's two that I want to discuss with you. There's the heart, their survival score and the Seattle heart term. Seattle Heart Failure Model Score. You look at the left side of graph. The Seattle heart failure model looks at survival based on numerous clinical parameters. Demographic information such as age, gender, functional, functional class, wait ejection fraction. Systolic blood pressure. Looking at medication profile such as diuretics. Um, headline directed medical therapy Looking at lab data such as hemoglobin, other markers of CBC, also uric acid levels and so serum sodium and then device supports, such as I CD or CRT or RTD. Um, and those are all kind of put into the system. And on that website you see there Seattle Heart failure model dot org's um, that's available. And then you can get a 123 and five year predictive estimate of survival for these patients with Hef ref Ato Baseline and then if they actually given intervention. And you could see that survival curve kind of to the top right of the of the table. The heart bare survival score uses seven variables listed here. Coronary disease bundle, branch block, LV function, heart rate, sodium map and VO two max as measured on a car department stress test. There's some peculiar fudge factors that we use, and then you some make those. You get a heart, their survival score. And at the bottom of that screen you'll see that the high risk patients have a certain delineation, medium risk and low risk. And, of course, we want to be favoring low risk patients as they seem to do the best. Yeah, so you've identified your patient who needs advanced therapies? Who is this individual? This individual, someone who just took their over 19 health stream quiz heading out that Santa Claus doesn't exist. Archaeologists who go to go lightly on a patient would see the colitis. Um, he was in office space will understand that fourth reference or we just triggered the work up for an elf course. The correct answer. L a bad world Cups are extensive and they include this. So when we're thinking l God, we're thinking we need a full body assessment to look, to make sure these patients and tolerate this pretty, um extensive, heroic, aggressive work up. I'm sorry, Aggressive surgery, and it really is kind of a full body scan. So to speak a Z we do. We look at different organ systems such as the kidneys, the G I tract, the liver, blood, the purple vasculature, pulmonary functions, infectious status, nutritional status, neurocognitive function, psychologic function. We look at human dynamic parameters. Eso we wanna make sure patients are adequately unloaded. Are they on inner tropes are they are finer strokes. We look at resistance is, um also want to look at imaging, so imaging includes CTS echoes Doppler. I want to make sure we pay attention to the RV. The right ventricle is often times that we called the for gotten ventricle. And I can tell you that anyone who practices advanced heart failure, especially the surgeons, we cannot forget the RV. Um, we were also in what, look a coronary disease to exclude any significant unpasteurized coronary disease that may need to be addressed. Arrhythmias need to be addressed A swell, Um, and, of course, a whole host of test that will go into We favor these workups in the Inter Max three patient to be done on the outpatients side. I think patients would appreciate not being imprisoned or elective outpatient tests, although their extensive these can all be done as outpatients. And so weaken Do these in our C v. C s. We could do this through, um, are outpatient heart hospital airway sweet for some of the C T scans. Cats can be done in the next three patients, which they come and they get done at heart hospital. They come in, they get a cat and they leave. So a lot of these can be done as an outpatient. But we do do some of them as an in patient. Some of these patients have come from several 100 miles away, and, um if they're coming from a couple 100 miles away, I think it's only ethical and kind to not have these patients go back and forth. So we, of course, aren't hardened fast about the outpatient rule. But it z ideal for the patient. Let's look a functional assessments. Let's look at a six minute walk. Six minute walk is easy, and it literally is exactly what it says it is. It's a six minute walk. We do these in every office that myself. Let's go to both at heart and in the outreach. So if you are Harker Heights First Town at Round Rock in Fredericksburg, Marble Falls in Saint Marcus in LaGrange on, of course, at Heart Hospital and any including any of the hospital, any of the officers I haven't mentioned a six minute walk is very feasible. You want to place two cones in a straight path about 30 m apart, and our Emma's do this. And so the EMAS initially measure blood pressure, heart rate, go to set it perceived effort, scale called it Borg skill and then, of course, distance. And then without provocation or without cheerleading, Um, you have to then have your patients walk for six minutes and you tell them, you know, bring your a game walk, but don't run and you basically document distance. And then so you take a 36 minute walk, vital sign assessment and a post six minute walk. Vital sign assessment and interesting as it sounds, so kind of willy nilly. But this has really been robust in terms of its predicted outcomes and the kind of key number to remember 300 m if those who walk less than 300 m or roughly three football field lengths in six minutes. If they don't do that, that's roughly equivalent to functional class four. I know people think of functional class for as bedridden and can't do anything, but it's actually not true. It's with symptoms at rest. But symptoms at rest doesn't mean the patients can't do stuff. It just means that they're not feeling well all the time. So functional class. For less than 300 m, those patients have been shown to have poor outcomes, and then there are some limitations to the six minute walk. Patient motivation, orthopedic issues, eso that has to be considered as well. We really feel for functional capacity assessment. Cardiopulmonary stress test has been quite helpful and really, for our practice revolutionary and identifying questions. We used to get the patient's heart rate and get them anaerobic. We use either a treadmill or a bike. A bike is an option. That treadmill is perhaps a better option if you look at bike versus treadmill. Your vo two max achieved on a treadmill is probably about 10 to 20% higher than on a bike for the same patient on the same day. So that's why we always favorite criminal. Additionally, on the bike for those patients who have pacemakers if they don't swing their arms, remember, the pacemakers respond to motion. So if your patients are moving their legs but not their arms as much, the pacemaker may not sense motion and their heart rate response. They may not have a corner public response. So another reason that we like the treadmill, those who do bikes and have pacemakers. We have figured out kind of a swinging arm protocol Thio kind of thought that, and to help us get the heart rate up, we measure a few variables and then condone a lot of calculations and the most robust numbers. We look at our the VO two max, the maximum consumption of oxygen and key numbers to remember our 14 leaders 14 millimeters per kilogram per minute or less, or less than 50% of predicted. Whichever is lower is thought to be a predictor of who outcomes. Another thing we look at is ventilation capacity and a V E B. C 02 slope of greater than 36 has been associated with poor outcomes. So we look at both those numbers in addition to a whole host of others to kind of identify you know who's sick and who's not sick. And US payers definitely look at this as determining in a determining way of who they would consider payment for l VADs you know, function all right. My most favorite subject as a heart specialist. I think my understanding of Ephron is not nearly as robust as an archaeologist, so I'll just briefly mentioned some path of physiology and we talk about this all the time. Everyone who comes into the compensated heart failure, cardio renal syndrome and you know it's kind of like you just want to sound smart card. It's a pretty complicated process. This nice review out of Jack, published a few years ago, shows that when you have the competence CHF there are two cardinal at the physiology is that lead to badness? One is if you have the composite heart player, I think we all appreciate that there's going to be a relative decline in cardiac output in cardiac index. If you have that and you look at the kind of the top part of that table, you'll have less flow to the body. So therefore, our trail under filling if you have less arterial under. If you have arterial under feeling less kind of load going to your body, um, then your neuro hormonal cascade gets activated. We all know in hardware that's bad. So your sympathetic nervous system, your ass access all gets amped up. That causes further ways of construction, and that decreases profusion to the kidneys, and that can worsen acute kidney injury. Therefore, one path the physiological mechanism for the cardio renal syndrome, the other one that I've appreciated more and more and more, um, is the Venus congestion so D complicated heart failure, human dynamic congestion. Your wedge pressures up. Therefore, the pressures to the right side. Go up. The right side of pressure goes up. Therefore, the pressures in your abdomen, your spanking circulation, your Venus circuit go up and therefore your kidneys get congested. So if your kidneys get congested, perhaps one way to make that better is to decongest them. And so that would be the role of maybe a diabetic. And so that's kind of the basic understanding of cardio renal syndrome. This is there's actually several types. This is type one, the most commonly understood, most commonly spoken about. There are several other types, but that's kind of the one. Let's listen here, um, so mental function. From my viewpoint, I look look out two or three kind of variables or two or three metrics when I see renal dysfunction, what's the CDP? What's the card index and what's the matter? CDP is the CDP high so that the idea that is this is there. Congestion thio the kidneys because if there's high cdp, the kidneys will be congested and they may fail or they may malfunction. So therefore, decongest in the kidneys may make that better. Thick Kartik Index, or arguably, from Revolution Kartik Index, are the kidneys getting perfusion. So on one hand, they're congested. On the other hand, are they getting in a flow? And in that realm, how do you get the cardiac index better? That's kind of a complicated question of you want at nine. A trope. Do you wanna after load? Reduce? But but that's something that could be considered as well where you could nae pride hydrazine miller known to tweak SPR or to improve cardiac output index to get food to the kidneys. Um, map is your profusion pressure to your kidneys? Okay, Do you have a map of 50? Maybe you have tow use basil constrictors to get better flow to your kidneys and again in doubt in these complicated patients, we have a pretty low threshold to get our neurologist on board. So, of course, in renal function, it's critical that we measure renal function for patients with and you know, the bedside exam, of course, is man or CPL. They will do a kind of a adjusted Krakoff GALT assessment clearance, and I think we're all comfortable with CKD Stage two so g f rs above 60 to say that those patients probably aren't at significantly elevated risk. CKD Stage three, which is the majority of our patients in clinic, do have some elevated risk for dance Arthur therapies. It's those whose G F r is a less than 30 that really we kind of start to take pausing. Are we doing the right thing? And remember, when we say a g f our of 30 50 it's a It's a rolling target. These kidney function changes all the time. So the creating of 2.500 mission maybe one on discharge because they were in party Rino syndrome there in cardiogenic shock. And I know Trump seemed to make that better. Or perhaps they came to the hospital. The renal function changed, and they're creating now. The reset hemostat is now is now two or three, and their G F R is bad. And they have stage five CKD. So anyways, advanced CKD for advanced hardware therapies is that, as that would imply, because the last thing you want to do is take a patient who has a g f. R of 10, but have added them on Lee for them to have to need dialysis. And we know that patients who go on dialysis within AL better patients already on dialysis we have gotten l've It's not necessarily in our center, but outside centers generally don't do well. I mean, that's just a not a not a great way to go. So the really the best assessment is a 25 year inflection for estimated for decimate VFR. So the G I evaluation is important. We get our G I specialist one your thinking, advanced therapies to do pretty much a screening, colonoscopy and endoscopy. Well, most of these patients are north of 45 years old, and if they are, then it's justified to do a colonoscopy. I think as for the most recent yeah, gastro association, um so screening colonoscopies just for malignancy rule out and then endoscopy. He's simply, as a source of, you know, there's so many patients who have asymptomatic do at night is gastritis, esophagitis. Last thing we want to do is find out the patient had a gaping also in their stomach, put him on anti coagulation because his dad's do require, um, you require Excuse me. They do require anti coagulation, and if they require anti coagulation, then the issue there would be, um, that they had blood thinners on board. They have a gaping ulcer and all of a sudden there bleeding. So I think that's important to know. Just as a zey point of reference in the Momentum three study, which was the heart made. Three study a quarter the patients studied over two years had G I bleeds. And so this is an important conversation up front to have with our patients saying that if you're getting a bad, there's a likely chance in your lifetime if you have a bad that you're gonna be dealing with the G, I bleed. You know, some jack leads or minor, but some could require hospitalizations. Repeat endoscopy balls. G Physicians continue that GI bleeds and bads are almost commonplace, so it's important to do that. Especially consider, um g I bleeding history in patients who have known a B. M s and a lot of G doctors find a VMS and the kind of zapped, um um is interesting word here, listed here called Heidi syndrome, that we're going to talk about Heidi syndrome in just a few slides, so I hope that that will make sense in terms that need. Hispanic evaluation is important too, and Hispanic evaluation is not necessary. The same thing is getting scope. It's actually looking at a functional illiterate. These patients are sick, and like any sick patient, the body starts to fall apart. Deliver can, like the kidneys can follow power, fall apart on two different kind of path. Physiologic mechanisms. One is ischemia. So, uh, you liver insult because the blood is not going to deliver. And then hepatic congestion because, like the kidneys can become congested, deliver can come suggested as well. And so there actually are two separate types of thematic injury. There's chronic, and there's accused, and we'll go to that in just a moment. But the presence of cirrhosis, patients who have synthetically dysfunction of the liver and then they have either radiographic or even biopsy proven cirrhosis probably should not be getting elevators. Those patients have a lot of other health concerns and bleeding tendencies and human geologic disorders. Putting of Adam. That may not be the best idea. So if you think about contraindications from a liver perspective, chronic liver injury so total billy above three cirrhosis or in meld score and the meld score is described for patients with liver disease. It's the bilirubin Einar serum creating and the presence or absence of dialysis. If the score is elevated, those should be all considered as contraindicated that these absolute I can tell you having been around the country and collaborated with folks thes are not absolute. I think a lot of these a relative, but it's fair to say that outcomes can certainly be tied to these thes disease states. And also equally important is when you see patients come to the hospital, you went. You may see our notes Megatech or in Epic saying this patient had acute liver injury and they had a significant Trans Am Munitis. The acute trans emanates from cardiogenic shock behaves a little differently than chronic liver disease. What I mean by that is you may see Lfp's rise into the thousands. Um, I don't think that any of us would would be eager to put a bad in those patients acutely, but I think it's fair to say that if that if that kind of peaks and then that curve flattens and then all of a sudden on the way out the lfp's have normalized as an outpatient, I think we would kind of look at that as an acute phase challenge and that that wouldn't necessarily be a congregation. Contraindications to a bad looking at your blood and coagulation profile. It's intuitive, but it's important to make. I don't have significant anemia because they're going to be married to Coumadin, and if they are and they have a hemoglobin of seven or they have 50 platelets, he's not gonna be a wise choice. And it's important to also rule out or evaluate for clotting disorders, because if patients have hemophilia or they have a tendency to have blood clots like acquired quite a sort of anti deficiencies, um, they're married to come in and for other reasons. And if they have GI bleeds, they can't stop. And they may have a clotting problem, and they could, God forbid, caught off their bad. So both pro and hemophilia kind of issues need to be addressed ahead of time. Daddy syndrome is an interesting name, but it's spelled this way. It's not Heidi as the females name, but it's actually described by position years ago, and it basically is acquired Valuable Brands disease. It was first described in G I bleeding and severe aortic stenosis and what what it represents is it's a lost of molecular weight. Fractions of one woman's uh This occurs in high shear stress and the lack of positivity. If you think of critical aortic stenosis, there's a lot of shear stress that mean great inquest. That aortic valve is super high. Maybe your ingredients 40 or 50 or 60. And if you have that, those patients with critical a s, their blood pressure, their their pulse pressure isn't 40 or 50 but it's like 20. It's 15 and so low pulse pressure, high shear. Stress those high molecular weight multi MERS of valuable brands it shared, and they get destroyed, and therefore you develop in a acquired waggle. Apathy, and you believe that's the air deck stenosis paradigm that totally applies to l bats. Remember Elvis L bads are are not pulse. It'll flow the heart made to the heart made. Three. There's a teeny bit of possibility within your ol vets, but there's still mostly pulse less so if you have, If you don't have pulse, it'll flow and you have a high shear stress through this metal turbine. Um, that could certainly cause this acquired a cooperative notice. Heidi syndrome. There's no specific cancer screen per se for patients. You know that in advanced heart fair work up. But arguably, it's an age appropriate cancer screens. So again, colonoscopies most these patients hi and endoscopy kind of becomes routine. Is part of that a mammogram and a prostate exam? They're not really Option a C T scan, of course, The Pan CT. We feel that we just want the surgeons to have good anatomy and good landing zones as to what's happening between just Elvis and remember for your patients being considered for advanced therapies. Um, if they had a history of same metastatic melanoma three years ago, um, they may not be a candidate for a heart transplant because those patients need to be cancer free for five years. Your breast cancer patient needs to be cancer free for five years. You're limp moment. Patient needs to be cancer free for five years before they could be listened for a heart. But they couldn't get a bad, and so that in that realm, they probably would get a if they, if they work up, is appropriate, a destination therapy bad. And then, once they hit the five year market, that nomenclature could be flipped to a B T T and that it could be listened for transplant. Vascular disease is important and perhaps something that we don't focus enough attention on. I think the surgeons can all kind of a tested this that you know what the plumbing look like, both as in the legs. And as the legs look. So does the heart, and so does the Mesen Terek system. It's important to make sure your patients don't have significant Ph. D. As when they get Kanye Lated on the bypass machine together. Bad we're using for arterials, whether it's actual or ephemeral or central. It's important to have your surgeons know what that anatomy looks like. But equally important is, um, if they have significant Afro sclerosis and the coronaries in their periphery, they probably have it in their gut. And I can tell you lesson Cherkasky Mia in the throes of cardiogenic shock is a horrible problem, and patients really spiral quickly and don't recover. If those patients and getting a bad, then we find out that they have significant misinterpret schema in that realm, then that's just a bad center. So it's important to do throw purple Vasko screen, which would include kind of the standard exams of looking in the legs, looking the abdomen, looking at products and the pan CT scan also looks for P ideas. Well, another important thing to look at his quality of life improvements in your patients with significant lower extremity ph. D Are they clawed against or are they cardiogenic? What's limiting them? And that could be sometimes hard to know. Hence the sea pet. So if there see pet is done and they have significant Ph. D. But they got there, they became anaerobic. They got the respiratory exchange ratio. There are er above 1.1, meaning they became anaerobic. Um, then perhaps they are cardiogenic, more nature by their limitation and less Claude Akins. I hope that makes sense. Lung disease. It's important to know that your patients have significant lung disease and ahead of, um, lung work up here. Which is pretty intuitive, of course, are radiographic imaging chest thing. Ah, formal primary function study and a car department stress test. The seabed. You know, we focused really on the cardiac features, but we've had patients actually come to our secret lab and their, um one. Their forks. Volume is very low, less than 50%. Their 02 saturation is very low there. See pet shows that they have a low vo two max, but they're breathing. Reserve is actually very low. That would be more reflective of a lung disease. Patients, they're pft s may reflect that as well. They're CT scans may show if robotic changes, they may have advanced primary disease, like emphysema or some blazing. It's important to get your lung doctors involved because I can tell you a bad lung fee. Advanced heart Thera therapy means bad lungs post, and the last thing you want to do is put a patient on a bad on event, and then we can't wind event and they go home with the trade what they don't know him at all. So remember that advanced COPD, although difficult, You know, sometimes they know who's moderate, whose advanced. That's what we did, the pulmonary people on board, If that's ever a question so again, we want to be cautious in patients who have a low FTV one, um, diffusion abnormalities described as less than 50%. Do you have your patients who have who have COPD, who are in that, you know, purported 50 50 club there po two in there Be CO two are both equal those problems. And of course, in patients who have advanced lung disease. They may have pulmonary hypertension, which may be mixed. And if they have significant public hypertension, those patients are at higher risk for RV failure. Post bad infections all makes sense. We wanna make sure that this metal device with with tubing and turbines and externalized Dr Lines are at lowest risk of infection possible. So those patients who attended be septic. Those patients who have been septic event days, they've had device leads infected. They've had open sores, diabetic foot ulcers, sacred Cuban. I, um, recurrent bouts, except septicemia like U. T. I S and pneumonias really have to be thoroughly evaluated if they have a local ketosis. If they have a dirty urine, we don't add them. We need to kind of make sure that those patients have been thoroughly treated for infections before the consideration of Al Bad, and the patients have unknown fevers and Lucas ketosis that really needs to be thoroughly evaluated by the heart. 13 and the consulting internal medicine team to ensure that these patients are not infected again. Pirates for Infections Poorly controlled Diabetics Patients were malnourished. Patients were immunocompromised, such as HIV or patients on steroids. Patients were getting active mechanical ventilation, so those patients were not hard to put in all that in them when while they're intubated and, of course, those who are in military in system failure again, those are probably the Interfax ones and twos that we're not looking good, necessarily bad right away. Nutrition is huge. I can tell you that when we see patients as late referrals, they do. And as this cartoon on the bottom tongue in cheek placed here, they sometimes do look like death warmed over. When we see a patient looks good technique and frail and their BM eyes 18 there, albumin is, too. They have a low cholesterol, they have a low lymphocyte, Um, they're functional, for they have a ambulatory elevated lactate. When we all acted in the cath lab, that's a bad sign. And again, it's important that there it's nice for them to be thin but not thin on a kind of Scaccia. It's also important for them not to be more with the obese. So I think there's a sweet spot of maybe a B M. I have somewhere between 25 maybe the low thirties to say that they have enough reserve, but they're not protecting and they're not morbidly obese. Um, nutritional status needs to be addressed before l've it, because if they go in malnourished and protect IQ, they will not do well. And it is fair to say on those Interfax threes who are malnourished. We would have them visit with nutrition. We would get them a structured kind of nutrition routine to beef up their stores before the consideration of an L VAD implant. And it's just an important note. I kind of address this, but of note here, beam eyes above 40 were excluded in some of the heart. First, the heart player, um, DT bad trials. Eso in my 40 was excluded. Does that mean that a B M I of 40 will be excluded? Let's now know necessarily, but I think it would take pause and everyone wears their weight differently. Some people are very top heavy. Some people are very pair shaped and bottom heavy. Aziz, long as way feel from a heart third team and the surgeons that cannula could go in with relatively little hindrance. Onda patients where that weight in a way that's conducive to the implant that that would be okay already discussed this all going so in terms of neurocognitive function in neurologic assessment its's all intuitive stuff. But we have thio way. Wanna make sure that C. T. Of the head gets a good kind of landmarks of no old strokes? We weren't aware of. No tumors, No bleeds. Andi, I'll tell you. Post bad. It's common, such as E start there this morning. Who's on VA ECMO? Not a bad per se, but we get head images off. It's always good to have a baseline equally important when they're on the bypass machine, getting the bad to look at the credit arteries to ensure that they don't have significant credit stenosis. Um, in terms of cancelation technique, one of our imaging paradigms is chest, abdomen, pelvis that we definitely want our surgeons to know. Does the patient have a porcelain, a order are the full of calcium or not? And then in patients who have cognitive impairment, we do have patients who and I think all of us have been fooled by our sometimes are 70 and our 80 year old patients, and even are not engineering's who really seem with it. But then all of a sudden they come to the hospital, they fall apart and whether Sun Downing or it's dementia unfolded, formal neurocognitive assessments can be helpful and teasing this out and having collaborated centers. Um, it's been interesting to kind of see them tease this out. And at a higher executive level of function, these patients fall apart. Remember, they have to be able to have some, um, manual dexterity, some higher order of thinking to manage these alarms. That could happen in the middle of the night. And that's of course, um, important with caregiver support as well, so significant of dementia. They may have the greatest body habits, the greatest body for a bad. But if their brain is not operating properly because of significant dementia, Um, it really is not a good idea. And this can really unmasked post so bad. So we take pause there. Psychosocial things perhaps cannot be stressed enough. Um, if patients don't have adequate caregiver support or adequate psychosocial support, home. This'll is not going to get better that, um we've been fooled. We being not just myself and, of course, but we being the hardware community, have been fooled many times in patients who come to the hospital feel sick. Um, cry wolf, saying I'll do anything and everything and family comes in from in town from out of town. And all of a sudden, once they leave and they go home not necessarily with a bad everything stops. So the idea that they're going to check their vital signs stops, they're gonna have caregiver support that just stops happening. We see them in heart, very follow up, and then sometimes they don't show up. And it's not because of the pandemic. They just don't show up because they don't show up. Um, sometimes they don't have characters supported follow up. So they're on Miller known, for example, and we see those patients again every 1 to 2 weeks. They don't get their labs, they don't know their meds. This happens all the time, and this is not to point fingers at patients. We ask a lot of them and asking patients to go home on Anna trope. Um get weekly labs come into six minute walks, document their vital signs while the 2 g sodium diet you know, food restrictions is asking a lot. I don't know if a lot of us on this call could do that. So when we asked them to do that when they're on their inner took challenge slash you know, trial. That kind of is a test drive, or can they handle a bad? It's not the same thing, but if they can handle the Latrobe, you know, regimen. Then perhaps the idea of an L VAD may be suitable and their wife shows up. Their kids show up and they're all hands on deck because I could tell you pathologic noncompliance does not get better post that I've written at the bottom here. Well, that's don't fix crazy. It actually may exacerbate this. It's happened, and I, I regrettably have have recommended alibied for patients in whom post bad the caregiver support stopped the patients. Um, I want a psychosis, but they're just non compliance was so obvious it really it hurts them in the end. And it was it was unfortunate, So it's important to exclude those red flags and That's why we get our social workers and our palliative care service line at Heart hospital on board early to make sure that they can tease this out as well. Our psychosocial evaluation is you know exactly what you think it is. Do you understand what I know that is doing what it looks like? Who's the caregiver? Who is going to be taking patients to and from visits? Whose gonna be doing dressing changes? Thes Patients need to have dressing changes done with aseptic technique. Do they have already, um, do they have the cognitive skills? Do they have coping mechanisms? I know this sounds kind of fluffy, but it's really important. I mean, we're asking more of our patients, and perhaps we actually asking ourselves. So is there compliance reasonably good? It doesn't have to be perfect, but it's got to be near perfect. I don't know that anyone is 100% compliant, but it's got to be pretty darn close. Mental health history. I don't know that patients who have a history, bipolar disorder, necessarily a contraindicated to an elevated, but if they're bipolar and they've been hospitalized that Joe Creek and their compliance is suspect I'll be not a good idea. Substance abuse. This is interesting. So is tobacco a contraindications in L. A bad? The answer is no, but I think it kind of it sheds light on decision making by the patient. You know, I think we all know that tobacco definitely impairs wound healing. So I think from a wound healing perspective and from a life choice perspective, we would kind of reason, eyebrows saying, Maybe this is not the best choice for them. But it's not a contra indication to Anel bad. It is a contra indication to transplant. You know, we're running a little short on time, but this kind of gets to the nuts and bolts of human dynamic. We want to make sure that when you see patients with becomes a hard player who are being considered for advanced hardware therapies, you want to make sure there's two things happening. Adequately unload the patient and make sure the patients blow to their body. Is that so? Unloading. Make sure him a dynamic congestion is improved. Him. A dynamic congestion is your edge in your C v P. And that could be your bedside exam, because you here in s three and you see elevated GDP, and that could certainly be your swan. So I'm sure that all of you feel similar to this. But I can tell you, from our perspective, we want to be aggressive. So when you see drips happening, when you Cebu Mexican to see Lasix at High King doses, we're monitoring equally closely. So we're getting BMPs maybe, say once, twice, three times a day. There really is no magic to treat volume overload. I think the important here importance here is be aggressive because we know that if you don't treat volume adequately the first time that those patients will come back, we get a nephrologist involved when we're having a hard time and they're on 40 Lasix an hour, they're on to a BMX an hour. They're on high octane diabetics. We still can't move the needle. Then we ask our favorite Effron to come and ultra for trade our patients, and that could be helpful to. But again, if that's happening, that can sometimes be a marker of poor outcomes on patients who might be eligible for that. And when we're thinking of Al. But we also want to make sure that these patients have of cardiac index of more than 2.2. If an Dragan profusion is good because the cardiac index is adequate, that's a good thing. If patients go into an L VAD with the cardiac index at 1.5, that's not good. That means that there and Rogan profusion is already bad. They endure the insult of a bypass pump, run the l bad bleeding, and then that may be a set up for disaster. So we wanna make sure that those two things are addressed ahead of time. And so that's the whole idea of if we can't diary such patient. Is this because the cardiac index is low? Should we add nine a trope? Should we increase the on a trope? Do we need to add temporary mechanical circulatory support like a balloon pump like ECMO or even an Impala? And in terms of Anna Tropic Support, you've probably seen this wilder known versus wti Mean Miller known is a fossil dinos. Raise three inhibitor and vitamin is a direct beta agonist, and we use these to directly act designer tropes and thio output index up and again, How do they work? The nuts and bolts of China tropes. Are they improved? Contract Il ITY contract Il ity increases so stroke volume increases and heart rate increases. Remember, your equation for cardiac output is struggling times heart rate. So if you're struggling goes up, your heart rate goes up. Your cardiac output was up there. There's your improvement in cardiac output. And if you divide that by B. S. A. You get an improvement in cardiac index. We sometimes favor Milburn own. Why? Why is that? Because if we have a patient on 50 mg of Marco Polo and we wish to maintain guideline record medical therapy, we would think that you do mean and a beta blocker would directly antagonize each other. So we feel that when use a fostered illustrates inhibitor that perhaps it works through different pathway, we can still maintain GMT, uh, specifically a beta blocker. And we can use a different mechanism of action in a trope that won't directly antagonized the effects of the beta blocker. So that's kind of the thought there really head the head Data is not robust in terms of which one is better. I think arguably Mitterrand is more visible, dilatory so It's pretty common that we start Laurent and blood pressure actually come down because it's a pretty robust vessel. Dilator. So SPR and PBR do come down, walk the things that we see. If you look at our cath reports on those who are those of us to do by heart. Cats are interventionists, um, so you'll see a thick cardiac output in index, which is we'll go in that disappointment. You'll see a thermal dilution, cardiac output index transforming ingredients. And then resistance is they've asked resistance and systemic fast on our cath lab reports, you'll see these numbers, and I just wanted to kind of briefly go over what they are and how we calculate them. So your cardiac output by thick in the numerous Zaha Yeah, in equation. So in the numerator, he's 125 times BSA as a constant. So let's just say an average BSA's too. So your new mayor is about 100 is too 125 times B s. A is the numerator. The denominator is a constant 13.6 times the hemoglobin times the ingredient. The ingredient is the arterial saturation off a blood gas or off a pulse ox as an estimate minus the mixed venous. So to set the mixed venous so to set is the distal off the swan. So your pedestal saturation Not your pho too. But your 02 sat so that is represented as a fraction. So this would be saying you're rto saturation will be 100%. Your mixed venous 02 saturation would say be 70%. So that would be one minus 10.74 point three. Here, you hemoglobin. Hemoglobin would say be 13. This is a 13.6 constant would multiply those three numbers 13.6 times, 13 by times 130.7 as the denominator. You put that into the numerator of of 250 as an estimate. And there's your cardiac out. I think it is that simple. Um, if you want an index, you have to index your body surface area. You divide that by B s. A. Um second common thing that we listen to Catholic reports is to transform ingredient. That's your p a mean minus wedge. Do you think of your transform integrating? What is the grading across the pulmonary story? What's the flow going in the pulmonary artery was the flow going out the pulmonary vein or the wedge pressure so that number should live around 8 to 12. So normally above 12 is high or above 16 is significantly high, less than native is still pretty normal. Um, how many vascular resistance is your TPG? Your transformative grading divided by cardiac caliphate. So the TPG, um, divided cardiac output above four. And the units here are would units so above four is a significantly high PVR 3 to 4 is kind of a gray zone. Less than three is normal. We throw around the words Excuse me. We throw around the words pulmonary hypertension a lot in the cath lab. We like to define public hypertension. Is this recap Hillary? Probably hypertension or post Cavalleri Pulmonary hypertension. Most capillary meaning left heart disease. Meaning CHF vocabulary. Meaning, um um, something else, Maybe lung disease. And so pre capillary pulmonary hypertension or pulmonary arterial hypertension has an elevated PVR. Post capillary pulmonary hypertension or heart failure from the hypertension has a low PVR. So the majority of people in America around the world who have heart there and have formally hypertension, pulmonary venous, hypertension or post capillary pulmonary hypertension for a PVR less than three. It's a lot of words. I hope that makes sense. But I think I wanna highlight that because we throw in. The words of Ph. PH should be distinct should be made distinct, at least in this very basic paradigm of Is this pH? Is this pvh or is it mixed? Oftentimes they're mixed, but I want you all to know, at least that's how we calculate that. Then there's Pappy. Pappy is three idea that weaken really kind of assess RV function by two different metrics in one equation. The pulmonary pulse pressure. The PS systolic minus diastolic. Do you think of your systemic blood pressure? Your you know, systolic blood pressure Minister Diastolic your systemic blood pressure. If it's narrow, you have a blood pressure of, say, 90/80. That's a pretty narrow post pressure that means your left ventricle probably pretty crummy. Think of the long side. If your RV functions pretty crummy, your PS, systolic and diastolic will be narrows well. And if you're Arby's crummy, your RV functions is not good. Your pressures go up. Our pressure. They're going up. Your post pressure is becoming more narrow. You're happy your public notary also guilty index goes down. So a normal pappy is above two or adequate borderline is 1 to 2 and less than one is concerning. I think we all would say that less than two is a problem. And then patients being concerned for advanced heart failure therapies, we need to be mindful of that. Another important ratio of CBP to wedge. You think of your wedge pressure Normally, say 16 15 or less. Your normal CBP is 3 to 5. Arguably, none of our patients in the Catholic have that. They all have been hired. We look at them as a ratio. If you're CBP, the wedge ratio is above two thirds. So if your C B C B P is a 12, your wedges 12 your ratios. One. That's a problem. Why is that? A problem with wedges? 12 12 is great. Your CBP is high. That means that you're right. Heart is struggling. And so TVP two wedge ratio above two thirds may suggest Harvey dysfunction. How do you calculate We just talked about PBR? How do you calculate systemic vascular resistance? Remember the PBR? It's the transplant grading the pressure in the lungs going in the pressure lungs going out divided by the cardiac output. So use the same paradigm in the systemic side. It's your apartment, your blood pressure going out, your map minus your blood pressure going into the circuit. You're right. Angel Pressure or CBP, divided by cardiac output. And by convention, we multiply that times 80 on debts to get this unusual. Units dines time seconds over centimeters to the fifth power. But if you do this without the factor of 80 it's you get would units. So going between would units and this factor is a factor of 80. How we doing on time? Um, let me see if we can these things here. So I'm sorry I'm a little short on time because we started late Course in the cath. We wanna look a coronary. Arteries wanna make sure that these patients have corner disease have been adequately pasteurized. Echo is important. It's important to use contrast. It's important to do a bubble study. The last thing that our heart, their positions we want to do is find out that the patient had a clot at their apex have apex a pickle clot. They can actually remove it during an al bad implant. It's always important them to know if they have a shunned. So we do bubble studies to exclude NASD, and again the committee meets. It's kind of the Knights of Roundtable. We've had several meetings already for patients to be considered for. That's hard there. I'm careful and over, team members say, When you're being concerned for advanced hardware therapies and we're meeting, it does not mean no that triggering the work up does not mean, you know, does that mean transplant? All it means is we're gonna think about it and it it takes a village to make these decisions, and these decisions can be difficult. They could be emotional, but as a committee, we stand together and we kind of vote we and and the voting is really it's. It's a multi disciplinary team. The meetings. We've had it heart. It's the bad coordinator. It's the heart player, a p p. It's the heart, their physician. It's the social worker. It's the nutritionists, It's the occupational therapists. All of us are there making these decisions as shared decision making because at the end of the at the end of the day. We want to take good care of our patients, and we don't want to set them up for failure. Appreciate the time I appreciate everyone's dedication to this endeavor. Um, uh, kudos to the team. The team. It is really a team approach to heart failure, and it takes passion. It almost takes a masochist to really enjoy this because, like this morning at 6 a.m. And we're transporting a patient on va ECMO, it took 10 patients to transport that patient, and I can't at the committee meetings. We're talking about one patient, but they're 20 people in the room talking about one patient, and that's kind of the stakes here. So if you refer patients for advanced therapies, please feel that you're part of the team. Though you may not be necessarily the heart there a PP, the heart, their position. Your voice is equally important because you may know the social dynamics atone. You may know the family dynamics in home. You may know substance abuse history or the history of incarceration and how that, you know, may play out and what what that looks like. So we lean a lot and We make a lot of informed decisions, sometimes with limited information. So please feel that you're you're all hands on deck, and it's gonna take a village for the success of our program. So, um, kudos to Dr Thomas. Dr Thomas, Christian Kirtland, the heart hospital staff and all of you Thio helped launch this program. And we're excited in the next few weeks to implant our first patient. So with that, I bid you do and thank you.