Evolution of late right heart failure with left ventricular assist devices and associated outcomes

Aug 26, 2023

Evolution of late right heart failure with left ventricular assist devices and associated outcomes

Right ventricular failure is a feared, yet too common, outcome following left ventricular assist device implantation. Dr. Jeffrey Teuteberg - ISHLT Past-President and the current Section Chief of Heart Failure, Cardiac Transplantation, and Mechanical Circulatory Support at Stanford University - discusses the risk of right ventricular failure after LVAD implant, and the risk of late right ventricular failure months to years after implantation.

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1.68 -> all right

2.639 -> so thanks everybody for uh uh jumping on

5.04 -> real quickly

6.24 -> um we've got a uh really interesting uh

8.96 -> guest and um uh

11.44 -> to to uh share a lot of information with

14.48 -> us today and very grateful that dr jeff

16.88 -> tedeberg's taking the time to speak with

18.64 -> us

19.6 -> just briefly i'd like to introduce dr

21.279 -> tudeberg to the group

23.199 -> he's currently the section chief of

24.72 -> heart failure cardiac transplantation

27.119 -> and mechanical circulatory support at

29.359 -> stanford

31.039 -> he sees patients both in the clinic and

32.96 -> hospital with advanced heart failure

34.96 -> those that have received cardiac

36.88 -> transplant or

38.32 -> mcs lvad durable albed in the past

41.68 -> dr twuderberg's research interests are

43.84 -> in clinical outcomes in patients after

45.68 -> transplant and mechanical circulatory

48.48 -> support

49.52 -> as well as novel approaches to

51.28 -> immunosuppression

52.8 -> he has participated in many single

54.64 -> center and multi-institutional research

56.64 -> studies

57.52 -> is published widely in the fields of

59.52 -> transplant and mechanical support

61.84 -> and served as the president of the

63.44 -> international society of heart and lung

64.879 -> transplantation in 2018.

67.36 -> i'm so a

68.96 -> person that has a lot of experience and

70.479 -> wisdom to share with us today then i'm

72.24 -> sure

73.119 -> um so uh dr tudeberg thank you again for

75.28 -> joining us and i'm pleased the floor is

76.96 -> yours

79.759 -> thanks so much

96.479 -> do you guys see like a full screen thing

97.92 -> are you seeing my presenter view uh it's

100.4 -> still taking time i think to right now

103.119 -> we just have a black screen still

117.2 -> let me try doing something real quick

138.4 -> all right

143.44 -> after two years and

145.04 -> this wouldn't be a problem uh let's see

148.879 -> why i want

150.239 -> this

152.16 -> we have plenty of time so just take your

154 -> time

171.76 -> there we go that should work let's see

173.92 -> if i can get it

178.72 -> how's that

181.12 -> is it showing under your right side

183.2 -> not yet i'm waiting yes now it is

185.36 -> perfect

186.56 -> all right

187.519 -> just there's a little bit of a time

189.04 -> delay from the west coast to the east

190.48 -> coast

190.99 -> [Laughter]

193.599 -> so

194.4 -> uh again i appreciate you guys inviting

196.159 -> me to talk with you today

198.48 -> i do have some

200 -> conflicts of interest to disclose many

202 -> of which revolve around mechanical

203.44 -> circulatory support

205.68 -> but now that we're down to one device i

208.239 -> guess i'm sort of

209.76 -> universally conflicted with some of the

212.159 -> information but again i think that a lot

214.48 -> of this stuff is relatively new and not

216.56 -> specific to any one particular device

218.48 -> and there's more specific to the field

220.56 -> so i

221.599 -> i thought i'd start with kind of a

222.959 -> handful of sort of introductory slides

224.799 -> to kind of give the sense of the

226.959 -> background upon which this paper is

229.04 -> based

229.92 -> and i think everybody recognizes that

232.159 -> this used to be a slide with a few

233.599 -> devices on it now it's just down to one

235.2 -> device the heartbeat three

237.439 -> and you know there's clearly a lot of

239.12 -> advantages to the to the newer

241.04 -> generations of device or issue than

242.799 -> should say the newer generation device

245.68 -> um in terms of outcomes and adverse

247.76 -> events and the like

249.599 -> but you know in the end the lvad is

252.08 -> still really dependent on adequate rb

254.159 -> function and i think it's one of the

255.28 -> things that we still struggle with

256.56 -> despite all the improvements in

258.079 -> technology because those improvements in

260.16 -> technology don't necessarily impact on

261.919 -> the right ventricle and i think we've

263.6 -> known for a long time that there's

266.08 -> impacts on the right ventricle

268.4 -> from um

270.479 -> for throughout the sort of whole course

271.919 -> of patients on lvads this is the first

274.08 -> big series of patients with continuous

276.479 -> flow devices that bob cormis and i

278.32 -> published along with others looking at

281.04 -> heartmate twos and not surprisingly this

283.52 -> has kind of probably been replicated in

285.36 -> almost every device that's out there the

286.88 -> patients with right heart failure tend

288.639 -> to do worse than the patients with no

290.32 -> right heart failure or when you sort of

292.08 -> look at innermax

293.919 -> sort of draw the lines over those you

295.759 -> know it's what we see in the early

297.52 -> trials is what we could continue to see

299.36 -> both with continuous flow devices as an

301.84 -> isolated lvad and frankly with

303.199 -> continuous flow devices when

306.4 -> tried to be implemented as biventricular

308.8 -> devices as well

311.039 -> so this is sort of hot off the presses

312.72 -> in terms of uh in terms of

314.96 -> new data but

316.56 -> this is what the most recent intermax

320 -> report looks like and it looks a lot

321.6 -> like the one we published a couple of

323.68 -> years ago in terms of

326.24 -> the percentage of devices and why this

328.08 -> sort of really matters is we sort of

329.52 -> evolved from a sort of half dt half btt

334.479 -> implantation to now almost 80 dt

337.759 -> is that the implications for right heart

340.16 -> failure so if patients don't do well and

342.08 -> their rv is not doing great then they

344.08 -> may be stuck with rv failure for long

346.32 -> periods of time so i think it's become

347.919 -> even more important that we sort of

349.12 -> figure out what's going on with the

350.32 -> right ventricle

351.68 -> and it's not just mortality and it's not

353.52 -> just some of the quality of life issues

355.039 -> it's all the other things that sort of

356.319 -> go along with it that make patients not

358.08 -> do as well and stay in the hospital for

359.84 -> a long time

361.039 -> uh you know they get stuck with gut

363.039 -> edema and they don't absorb their

364.319 -> medicines and their nutrition is not so

366 -> good and

367.12 -> it impacts their exercise

368.8 -> capacity in addition to their the the

371.36 -> lvad itself

373.919 -> so if you kind of say okay what do we

376.24 -> mean by right ventricular failures

377.84 -> traditionally it's been described as the

379.919 -> need for an arvad or prolonged dynatrips

382.639 -> and even the definition of quote unquote

384.88 -> prolonged dyna tropes is a little bit

386.319 -> variable it's anywhere from seven to

388.319 -> maybe 14 days post-operatively

390.639 -> although for

392 -> you know the folks that are in the field

394.08 -> you know they recognize that sometimes

395.44 -> patients are on on a trip for that long

397.36 -> for other reasons or maybe that you know

399.919 -> if you if you turn it off at

401.919 -> day 9 and you're looking at 10 days for

405.039 -> for rv failure is that really a big deal

407.039 -> or if you could keep it on today 11 and

409.199 -> you count 10 days as rv failure does

411.36 -> that really make the person

412.96 -> do that much but much worse so it's not

415.759 -> really based upon any

417.599 -> solid definition but it's sort of the

419.039 -> definition that we've been stuck with

420.319 -> for a long time

422.4 -> but we also know it's kind of when you

424.08 -> get beyond the first you know couple of

427.599 -> weeks post implant that there's still an

430.08 -> impact of rv failure when you sort of

432 -> look at this data from intermax from a

434 -> number of years ago but the data still

435.68 -> looks the same

436.96 -> if you look at right heart failure in

438.639 -> green the sort of risk is highest early

440.96 -> not surprisingly just given the the

442.88 -> patient's condition and that the

444.08 -> perioperative period but it still kind

446.08 -> of lingers on thereafter

448.72 -> and so when we sort of thought about

450 -> sort of ways to predict right

452.24 -> ventricular dysfunction there's been

454.24 -> lots of models and the reason we have

455.759 -> lots of models is none of them are all

457.36 -> that good

458.479 -> for a variety of different reasons

460.639 -> including pump types and what they look

462.8 -> at and how you define rv failure and a

464.72 -> lot of other things

466.479 -> and i think that you know we still look

468.16 -> at the right ventricle and try and make

469.759 -> some decisions based upon the way the

471.28 -> echo looks or where ct scans look and

473.919 -> you know looks can be deceiving and i'm

475.44 -> not a big believer in sort of the way

477.039 -> the rv looks

478.639 -> on an echocardiogram although i think a

480.319 -> lot of people sort of default to that

482.16 -> you know i think you need

483.68 -> things that are a little bit more

485.36 -> specific rather than just kind of the

487.039 -> eyeball testing you know some of those

488.319 -> things have been developed over time

490 -> with echocardiography but again i don't

491.759 -> think anyone is necessarily better than

493.84 -> the other and it's usually sort of a

495.52 -> combination of factors and typically is

498.08 -> a combination of factors plus kind of

499.84 -> local expertise

502.24 -> and ultimately hemodynamics are the best

503.919 -> things and i won't go into the gory

505.12 -> details about all the sort of right

506.4 -> heart hemodynamics but there's also a

508.08 -> lot of things you can look at and again

510.479 -> not one thing is is the thing i think

513.2 -> the more things that sort of point in

514.64 -> the direction of rv failure the higher

516.399 -> the risk

517.44 -> but it's still not a perfect predictor

519.36 -> of what's going to happen and when you

520.64 -> sort of

521.519 -> look at

522.64 -> more complex relationships

525.04 -> from intermax about all these different

527.12 -> things with one another

529.04 -> again i think that some of the

530.32 -> predictors may be a little bit stronger

531.839 -> than the others but i don't think

532.8 -> there's one in particular that that i

534.72 -> use that i find is like the the ultimate

537.04 -> predictor it's kind of

539.04 -> that combined with some echo parameters

541.12 -> combined with kind of

542.959 -> what the risk is for the patient

545.12 -> you know i think people looked at things

546.48 -> like strain and this is data from my

548.08 -> colleague from back in pittsburgh and

549.519 -> now is out here in san francisco uh ucsf

552.56 -> uh mark simon you know and i think these

554.56 -> sorts of measurements in terms of

556.32 -> looking at sort of novel

557.92 -> assessments of the right ventricle will

559.44 -> be important over time um but again i

562.72 -> still think it's still

564.64 -> a lot of this sort of prediction is

565.839 -> still in its infancy

567.44 -> and one of the other kind of major

568.64 -> limitations of sort of thinking about

570.08 -> right ventricular dysfunction is that

572 -> all these risk scores you have

574.32 -> some characteristics that you look at

575.839 -> whether it's the patient or whether it's

577.44 -> the hemodynamics or whether it's the

579.04 -> echocardiogram or all of those things

581.36 -> and you look at some outcome which is an

583.68 -> arvad or early or later inotropes and

586.56 -> then you kind of figure out what your

587.68 -> predictors are

589.12 -> but there's so much that happens in the

590.56 -> operating room

591.76 -> that can really impact what what happens

594.8 -> with the right ventricle you can take

596.24 -> someone who has a pretty normal right

597.839 -> ventricle and otherwise a pretty low

600.16 -> predicted risk of right ventricular

602.16 -> dysfunction and if you get into

604.16 -> something that bleeds you get a lot of

605.519 -> blood products and you kind of flood

606.88 -> their lungs and you get trolley then all

608.64 -> of a sudden that puts a lot of stress on

611.04 -> the right ventricle and you end up with

612.48 -> right ventricular failure

614.48 -> on the on the flip side of that if you

616 -> take somebody with a very marginal rate

617.44 -> venturable by whatever criteria you want

619.36 -> to use and you can get the person

620.72 -> through the operation without a lot of

622.24 -> bleeding and you know without a lot of

624.64 -> muscle fuss and that person may actually

626.64 -> do fairly well so

628.32 -> most of these things don't take those

630.32 -> intraoperative

632.48 -> effects into account

634.48 -> that earlier study that i showed you

636.399 -> with

637.36 -> heartmate twos that that was kind of the

639.44 -> first kind of big continuous flow look

642.16 -> at right ventricular dysfunction did

644.48 -> actually look at the operating room

645.76 -> because i think one of the things that

647.04 -> that bob was pushing for

649.12 -> as we were pushing putting this together

650.72 -> was you know what happens in the

652.56 -> operating room and is there a way to

653.76 -> quantify that and we see that the

655.44 -> patients who have longer or times

657.6 -> particular patients who have longer or

659.04 -> times and lots of bleeding tend to have

661.6 -> right ventricular dysfunction so i think

663.6 -> what happens in the r matters and i

665.04 -> think it's something that these

666.079 -> predictive things don't really take into

667.68 -> account

668.64 -> and i think that there's also sort of a

671.44 -> growing thought that oh maybe we can

672.72 -> just treat it afterwards and it's not

674.24 -> that big of a deal and i'm not so sure

675.92 -> we're great at that either

678 -> i think people sort of tend to go to

679.68 -> things like celenophil and this is a

682.32 -> large study looking at patients from

684 -> intermax or onsildenafel and looking at

686.72 -> survival over time and actually patients

688.32 -> are on so dentapill tend to do worse and

690.079 -> tend to have more right heart failure

691.839 -> now is that an impact of sildenafil

694.16 -> itself is that an impact for the

696.24 -> patients who are higher risk the year

698.48 -> and so those the patients you're

699.76 -> treating with cell dentaphil so they

700.959 -> have worse worse outcomes i tend to

702.959 -> favor probably the latter rather than

704.399 -> the former but it shows you just just

706.8 -> because these things are available i'm

708.32 -> not sure they're super effective uh in

711.68 -> their impact on the person's right

713.279 -> ventricle over time

718.639 -> so that was kind of the basis of

721.2 -> thinking about the paper that i'm about

722.88 -> to present and so the other thing that

724.639 -> we that i think everybody recognizes the

726.72 -> degree of rv failure matters as i showed

728.8 -> you a couple of slides ago if you just

730.639 -> do it as rv failure equals an arvad or

733.839 -> equals ionotropes for 14 days post-op

736.8 -> it's kind of relatively limiting but

738.56 -> when you kind of look at larger patient

740.399 -> populations in this case an intermax and

742.88 -> and look at sort of okay what is the

744.639 -> definition of rb failure is it what is

747.2 -> the duration of ionotropes is it less

748.72 -> than seven days which i think we'd all

750.32 -> agree pretty much everybody's on some

751.839 -> sort of signiture for the first week

753.519 -> postoperatively or is it you know some

755.839 -> gradation up to three weeks or is it an

757.68 -> arvad you see the longer you need

759.76 -> support or the more aggressive support

761.76 -> in the case of an arvad the worse you do

764.24 -> over time

766.639 -> and it's not just sort of time to death

768.72 -> when you look at time to death heart

770.24 -> failure and things like gi bleeds you

772.32 -> can see the same thing the patients with

774.48 -> they require longer durations of support

776.639 -> or higher degrees of support in the case

778.48 -> they are bad tend to do worse over time

783.76 -> and then that kind of gets us into

785.519 -> thinking about well you know

787.36 -> if there's if there's if there's not

789.44 -> only kind of different degrees of right

791.04 -> heart failure there's a sort of

792.56 -> different time frame of right heart

794 -> failure as well

795.36 -> and this is um jonathan's rich kind of

797.519 -> who's the first kind of big publication

799.68 -> with continuous flow devices looking at

801.92 -> the sort of phenomenon of late right

803.68 -> heart failure so what constitutes late i

806.639 -> don't know that we all necessarily agree

809.2 -> but in this case if you look at patients

811.92 -> who

813.44 -> were quantifying right heart failure

815.04 -> after their discharge from the from

816.72 -> their implant hospitalization the people

819.12 -> who developed late heart failure not

820.48 -> only

821.6 -> didn't do as well in terms of survival

823.36 -> but things like quality of life for

825.12 -> worse as well

828.32 -> so

830.079 -> as all this data was kind of being put

831.6 -> together a number of years ago

833.92 -> intermac said well we recognize that

836.639 -> the definition of argument failure is

838.24 -> inadequate so rved plus ionic trips for

840.32 -> 14 days isn't really great so

844.88 -> in an effort to try to sort of clarify

846.72 -> some of these issues in terms of the

848.16 -> degree of right heart failure and the

849.92 -> timing of right heart failure

852.56 -> we developed a definition that i think

854.88 -> is probably in in retrospect too complex

857.279 -> but tried to kind of get at these things

859.6 -> so right heart failure required some

861.92 -> sort of elevation of cvp or

863.44 -> manifestations of that elevated cdp and

865.839 -> i'll show you what that looks like in a

866.959 -> second

868.079 -> and then

869.199 -> it talked a little bit about severity as

871.519 -> well of the right heart failure and then

873.279 -> it also allowed you to look periodically

875.92 -> do you meet these criteria for rv

877.839 -> failure over time so as it followed up

879.6 -> three months six months 12 months and

881.199 -> then every six months thereafter

883.76 -> so again we're trying to get at the

885.68 -> degree of radar failure and then the

887.44 -> timing of right heart failure over time

891.199 -> so that kind of formed the basis of this

892.959 -> study so once we made that change in

894.56 -> intermax we went back after a number of

896.8 -> years to say okay what is this right new

898.72 -> right heart failure definition telling

900.639 -> us

901.519 -> and so the study that we're going to

903.44 -> spend the rest of the time talking about

905.279 -> is is this one and so this was from

908.56 -> patients that were implanted from 2014

910.88 -> through 2017

913.199 -> so it's about 8 000 patients if you look

915.44 -> at the patients who had continuous flow

918.32 -> devices

919.44 -> there's you know about 7 500 patients

921.76 -> and we wanted to look at patients at

923.44 -> three months because we wanted to have a

925.519 -> special look at what we thought was

927.76 -> quote unquote late right heart failure

929.839 -> so beyond three months and again we can

931.839 -> talk in the discussion period about

933.12 -> whether that's late or not

935.199 -> but when you look at patients who are

936.72 -> live on uh device with three months of

938.959 -> follow-up we basically group people into

942 -> that time period as having no right

943.759 -> heart failure mild right heart failure

945.279 -> or modded to severe right heart failure

947.279 -> and then follow them over time over the

949.36 -> course of 12 months of support to see

951.279 -> sort of not only what the impact of

953.279 -> right heart failure at three months

954.8 -> would be but what the change in rhetoric

957.279 -> would look like over time so if you had

959.519 -> no right heart failure were you likely

961.839 -> to get it later on if you had a lot of

963.519 -> right heart failure early on does that

964.959 -> mean you stay that way

968 -> so this was the

969.36 -> uh sts center max definition of right

971.279 -> heart failure basically you had to

972.72 -> either have documentation of elevated

975.44 -> central venous pressure by the things

977.36 -> there i won't go through them and read

979.04 -> through them all or you had to have some

980.56 -> sort of manifestations of elevated

982.72 -> central venous pressures

985.04 -> and so we're when we're trying to sort

986.32 -> of figure out who to include we said

988.24 -> well you know it could be one one of

990 -> these things or the other one but we

991.839 -> decided to include just patients with

993.6 -> both of them to make it a little bit

996.48 -> more likely that that person truly had

998.88 -> right heart failure

1000.399 -> now you can say well i can think of

1002.16 -> things that would give you elevated cvp

1005.199 -> and manifestations of elevated cvp that

1007.68 -> maybe aren't necessarily right heart

1009.199 -> failure and and i don't disagree with

1011.199 -> you um but that's kind of the way kind

1013.68 -> of what we're stuck

1015.04 -> with the definitions maybe we can talk a

1016.32 -> little bit about that in the discussion

1018.16 -> period so he had to have both

1019.92 -> documentation of elevated central venous

1021.759 -> pressures and some sort of manifestation

1023.44 -> of those as well as documented in the in

1026.24 -> the database

1027.6 -> when patients come back to clinic

1030.72 -> the other thing to keep in mind with

1032.72 -> this is

1033.919 -> that

1035.36 -> we knew with the introduction of this

1037.76 -> more complex definition of right heart

1039.439 -> failure would be more of a burden on

1042.16 -> those who are entering data into the

1043.76 -> intermax database which is typically the

1045.36 -> vag coordinators and they're already

1047.36 -> sort of overworked and overstretched

1049.679 -> as it is so we wanted to try and make

1052.24 -> this a little bit easier and the way we

1053.919 -> decided to make it a little bit easier

1055.44 -> is the way we coded the timing of right

1057.919 -> heart failure so we thought it would be

1059.76 -> pretty impossible for people to go back

1061.52 -> and say okay on you know

1063.919 -> june 3rd of 2021

1066.88 -> you met these criteria

1068.88 -> i just don't think we would ever really

1070.24 -> get those dates so we basically looked

1072.48 -> at time points and that's the way we

1074.24 -> should interpret the data for the rest

1076.08 -> of the study when you're looking at

1078.16 -> the evolution of right heart failure

1079.679 -> over time

1081.12 -> so as the slide here shows that at some

1083.6 -> point at the beginning of the time

1084.72 -> period say three months and the time

1086.32 -> point ends at six months

1088.4 -> and so if you can say okay at six months

1090.96 -> did you have right heart failure

1092.24 -> basically it's looking back in time

1094.559 -> did you meet these criteria which you

1096.08 -> can see this little table inset at you

1098.559 -> know whatever time x we're not

1100.32 -> documenting that timex but if you met

1102.48 -> the criteria for right heart failure

1104.96 -> between three months and six months at

1106.64 -> six months you would say you would be

1108.32 -> categorized as having had right heart

1110.72 -> failure and then we would categorize the

1112.4 -> severity of the right heart failure so

1114.559 -> it didn't matter if it happened here or

1116.799 -> if the right heart failure happened here

1118.88 -> as long as it happened before you got to

1120.4 -> six months but after

1122.559 -> three months which was the time period

1123.919 -> before

1124.96 -> then you were counted as having right

1126.559 -> heart failure at whatever degree at six

1128.64 -> months and even if you had

1130.88 -> a couple of episodes of red heart

1132.24 -> failure you were just you were just

1133.919 -> coded as having whatever the more severe

1136.16 -> episode of right heart failure was at

1138.16 -> that uh time point ending so again

1141.52 -> whether it's between three and six

1142.88 -> months or whether it's been swinging six

1144.32 -> months and 12 months

1145.84 -> that if it happened between those two

1147.679 -> time periods that right heart failure

1149.2 -> episode was attributed to the end of the

1151.36 -> time period that you're looking at

1155.52 -> i won't spend much time on sort of the

1157.44 -> patient characteristics so these are

1158.88 -> just sort of what the patients look like

1160.48 -> at three months overall and by

1162.799 -> categories of right heart failure no

1164.4 -> right heart failure mild right heart

1166.24 -> failure or moderate uh

1168.4 -> right heart failure as you can see that

1170.4 -> for the most part that there were well

1172.08 -> there were differences between the

1173.28 -> groups typically the folks with more

1176 -> severe degrees of right heart failure

1177.679 -> had more severe

1179.52 -> manifestations of elevated right-sided

1181.919 -> filling pressures or pulmonary

1183.2 -> hypertension or more commonly had right

1186 -> ventricular dysfunction or had low

1188 -> sodiums or high creatinines there wasn't

1190.4 -> dramatic differences between the two but

1192.16 -> they're signifi statistically

1193.52 -> significant but you know i think we

1195.28 -> would all recognize that patients who

1197.2 -> had previous right heart failure

1199.6 -> by the time you get to three months that

1201.2 -> their baseline characteristics are going

1202.799 -> to look a little different

1206 -> so just looking at prevalence of right

1207.76 -> heart failure over time and this is the

1209.76 -> only time where we included severe right

1212.08 -> heart failure which is by the definition

1214.08 -> of this study was needing an arvad

1216 -> because the the reviewers said well you

1217.84 -> know you said it wasn't very common can

1219.679 -> you prove to us it wasn't very common

1221.919 -> and the reality is is you know if you

1223.6 -> get to beyond one month the incidence of

1226.4 -> subsequent arvads thereafter are really

1228.88 -> really low so we're mostly looking at

1231.28 -> people who either require admission for

1233.679 -> diuresis or required mission for

1235.36 -> ionotropes and diuresis and pump

1237.12 -> adjustment there's very very few

1240.32 -> late right heart failures that require

1242.08 -> right ventricular support

1243.84 -> or maybe that at least that we're

1245.6 -> hesitant to put in right ventricular

1247.36 -> support late some of them may require it

1249.28 -> but we just don't put it in

1252.08 -> so

1253.28 -> what did what did things look like in

1254.799 -> terms of just mortality so again all

1256.72 -> these patients survived to three months

1258.799 -> and then three months they were

1260.159 -> categorized as did they have right heart

1262.24 -> failure between one month and three

1264.32 -> months because that's the interval

1265.919 -> that was the sort of interval looked at

1267.76 -> uh before three months to determine

1269.36 -> whether or not you had right heart

1270.48 -> failure at three months

1272.08 -> and you can see that if you had no right

1274 -> heart failure which is in green mild

1276.159 -> right heart failure which is in blue or

1277.6 -> moderate to severe right heart failure

1279.76 -> which is in the oranges color the

1281.6 -> patients who did not have right heart

1283.36 -> failure had a much lower cumulative

1285.6 -> mortality over the subsequent

1288.08 -> nine months so getting out to getting

1289.919 -> out to a year than either of the right

1291.919 -> heart failure groups and not

1293.039 -> surprisingly the mild heart rate heart

1294.48 -> failure did better than the the moderate

1296.72 -> right heart failure

1298.159 -> when you look at sort of total patients

1299.52 -> at risk most of the patients in the

1301.36 -> study didn't have right heart failure

1303.12 -> between one month and three months so

1305.2 -> it's about 5 500 patients and only about

1307.6 -> 300 patients in the mild and moderate to

1310 -> severe so even when you're kind of

1311.28 -> looking at this big group of patients

1313.44 -> between one month and three months when

1315.84 -> when you're looking at the incidence of

1318 -> occurrence of right heart failure as

1319.36 -> defined by the study it wasn't super

1321.44 -> common

1326 -> then the question sort of becomes well

1327.44 -> if patients are still alive what is what

1329.36 -> are the competing risks look like i

1331.039 -> think you're all used to sort of seeing

1332.24 -> competing risk analysis and that's these

1335.36 -> two curves a and b and so instead of

1337.84 -> looking at

1339.919 -> no right heart failure and looking at

1341.2 -> the competing risks we just did the

1342.72 -> individual competing risk to say you

1344.4 -> know maybe the patients who had moderate

1346.48 -> right heart failure were transplanted

1348.4 -> more often or maybe the patients who had

1350.24 -> no right heart failure were transplanted

1351.76 -> more often and so if you look in

1354.64 -> panel a which is on the left

1356.88 -> the patients are all surviving to three

1358.559 -> months and when you look at mild

1361.2 -> moderate and no radar failure the same

1362.96 -> colors as the prior slide

1365.039 -> you can you can really see that the

1366.72 -> incidence of death was higher in the

1368.48 -> group with moderate radar failure and

1370 -> the incidence of death was much lower

1371.84 -> than patients with no right heart

1373.12 -> failure but when you look at b and the

1375.919 -> incidence of transplant then we see the

1377.76 -> same thing with the incidence of just

1379.6 -> pumped and the either pump being

1381.44 -> explanted or turned off or whatever for

1384.24 -> whatever other reason

1385.84 -> we didn't include this in the study

1387.28 -> because the numbers were really low so

1388.88 -> the patients were doing poorly with

1390.559 -> right heart failure at three months

1392.48 -> because they were dying not because

1395.36 -> of a difference in transplant when you

1396.96 -> look at the transplant rates between

1398.559 -> those three groups it really wasn't

1400.96 -> significantly different over time

1403.28 -> so the patients who had worse degrees of

1405.44 -> right heart failure were doing worse at

1407.28 -> 12 months because they were dying

1411.679 -> what other things do we look at so we

1413.039 -> tried to look at gfr over time

1415.36 -> there was much more of this data than

1418.08 -> some of the other data i'll show you

1419.28 -> over the course of the next couple of

1420.559 -> slides the patients who had

1422.88 -> no right heart dysfunction at three

1424.799 -> months

1425.679 -> tended to have better renal function

1427.2 -> they tend to maintain better renal

1428.96 -> function over time than the groups who

1430.64 -> had right heart failure which isn't a

1432.559 -> surprise but it's nice to see

1433.76 -> documentation of that at least over the

1435.44 -> first year and we understand there's a

1437.44 -> lot of other things that contribute to

1438.64 -> renal function not just right heart

1440.08 -> failure so there's other things going on

1442.159 -> here but in general patients whose right

1444.32 -> hearts work tend to have better renal

1446.48 -> function

1448.48 -> when we looked at other things like

1449.6 -> quality of life which is on the left by

1451.279 -> a visual analog scale and six minute

1453.2 -> walk test we saw the same sorts of

1455.44 -> trends over time

1457.6 -> the caveat being that these data had a

1460.08 -> lot of missingness um so they're

1463.039 -> particularly the six minute walk

1464.32 -> distance uh when you look at the visual

1466.72 -> analog scale

1468.48 -> at three months the patients with no

1470.08 -> right heart rate heart failure tended to

1471.84 -> have slightly better quality of life but

1473.6 -> interestingly kind of over time despite

1476 -> the survival not being as good and

1477.6 -> adverse events being higher which i'll

1479.039 -> show you in a couple of slides there

1480.559 -> really wasn't a difference in quality of

1482.08 -> life now i don't know if this was

1483.6 -> because

1485.2 -> there wasn't really any difference in

1486.48 -> quality of life because we're using the

1488.64 -> wrong measures to assess quality of life

1490.4 -> or this all has to do with the

1491.6 -> missingness of the data for the quality

1493.279 -> of life it probably is a maybe some

1495.2 -> contribution of all those things and the

1497.279 -> same thing with a six minute walk in

1498.799 -> general patients who had no right heart

1500.64 -> failure tended to have a better six

1502.48 -> minute walk at baseline so at three

1504.4 -> months

1505.44 -> and when you follow them over time their

1506.96 -> exercise capacity tended to be better at

1509.039 -> least as measured by six minute walk

1510.799 -> than the patients who

1512.24 -> had some degree of right heart failure

1514.24 -> at three months

1515.52 -> again again just kind of emphasize

1518.48 -> the categories you're putting at three

1520.08 -> months these are sort of just assuming

1522.08 -> you stay in those categories as sort of

1523.919 -> irrespective of whether you developed

1525.679 -> right heart failure later or not and

1527.2 -> i'll get to i'll get to sort of

1529.039 -> what that change looks like over time if

1530.88 -> any uh near the end of the presentation

1535.679 -> so what about other adverse events and

1537.2 -> this will be the next several slides so

1539.6 -> and i think all of us thought that there

1540.88 -> would be a difference in some of the

1542.32 -> major adverse events for patients with

1544.24 -> right heart failure

1546.48 -> not necessarily because there is a

1548.64 -> causal relationship although sometimes

1550.4 -> there's a causal relationship

1552.32 -> but maybe just kind of with all the

1554.24 -> associated morbidities of being in the

1555.919 -> hospital and interventions associated

1557.52 -> with some of these other adverse events

1558.96 -> as well

1560 -> but be that as it may when you look at

1561.84 -> the incidence of re-hospitalization

1564 -> it's higher in patients who have right

1565.6 -> heart failure

1567.44 -> at three months compared to the patients

1568.88 -> who did you know not dramatically so but

1570.88 -> you know it's there's still there's

1571.919 -> still a difference and maybe there's not

1573.76 -> a huge difference between mild and

1575.36 -> moderate right heart failure

1578.4 -> we also looked at incidence of second

1579.96 -> rehospitalization just to kind of get at

1582.559 -> well you know maybe someone comes in for

1584.24 -> something that's relatively minor but

1585.84 -> they require

1587.52 -> so

1588.48 -> let's look at secondary hospitalizations

1590.159 -> just to see if that sort of same trend

1591.76 -> holds and it does i think this the

1593.679 -> degree of difference was about the same

1595.84 -> and the difference the different the

1597.76 -> difference between those with none and

1599.52 -> those with some right heart failure

1601.44 -> is there and the patients who had

1603.279 -> degrees of difference in radar failure

1605.12 -> weren't all that different similar to

1606.559 -> the first hospitalization

1610.96 -> what other things are gi bleeding so the

1613.6 -> upper left is the incidence of first gi

1615.919 -> bleeding and uh the the bottom right is

1618.72 -> incidence of second gi bleeding clearly

1620.96 -> the the incidence of first gi bleeding

1622.96 -> is lower in patients with no right heart

1624.64 -> failure at three months there's less of

1626.559 -> a difference but still a statistically

1628.559 -> significant difference for the incidence

1630.159 -> of second gi bleeding

1632.4 -> which again kind of gets into this you

1633.919 -> know how much of this is because of the

1635.44 -> right heart failure and how much is

1636.72 -> because of other things and other

1638 -> adjustments and other comorbidities that

1639.6 -> go along with right heart failure

1643.84 -> other major adverse events so if you

1645.6 -> look at stroke there's a there's a

1647.039 -> significant difference not as dramatic

1649.279 -> as something like gi bleeds or

1650.52 -> re-hospitalizations but the group with

1652.32 -> the lowest incidence of stroke

1654.48 -> was in patients who had no right heart

1656.399 -> failure and as you recall from the very

1658.64 -> beginning of this there were very few of

1660.799 -> any heartmate threes in in this in this

1663.36 -> group of patients actually i think there

1664.64 -> were no heartmate threes so this is

1666.559 -> still a group of patients who are

1667.76 -> predominantly heart mate twos and hbads

1670.72 -> uh when you look at something like pump

1672 -> thrombosis which we tend to sort of

1673.52 -> associate with the heart mate ii or at

1675.039 -> least higher incidence in the heart mate

1676.72 -> two that didn't seem to be a big impact

1679.039 -> on right heart failure status in three

1680.64 -> months on the subsequent development of

1682.88 -> pump thrombosis

1684.799 -> between three months and 12 months

1690.08 -> and then lastly if you look at something

1692.159 -> like

1692.96 -> that associated infections a non-vet

1694.799 -> associated infections

1696.559 -> those who had no right heart failure or

1698.64 -> lower degrees of right heart failure

1700.159 -> tended to have fewer

1702.32 -> uh cumulative incidents of

1705.76 -> infection over time whether it's sort of

1707.6 -> infection in general or bad specific

1709.36 -> infection

1712.96 -> so the last couple slides i would just

1715.12 -> want to show you are there they're

1716.72 -> sankey diagrams and

1719.12 -> we chose to use these because we thought

1722.159 -> it kind of best represented what happens

1724 -> with patients over time so let me talk

1726.32 -> you through these next few

1728.03 -> [Music]

1729.44 -> next few slides so if you look at this

1731.44 -> panel so this is a group of patients who

1733.44 -> had no right heart failure at three

1735.2 -> months so again between one month and

1737.44 -> three months they had no episodes of

1739.12 -> right heart failures they were

1740.24 -> categorized at three months as having no

1742.159 -> right heart failure

1743.679 -> and then what happened with what

1745.36 -> happened when you looked in the at their

1747.279 -> six-month follow-up and what happened

1748.64 -> when you look at them in their 12-month

1750.08 -> follow-up

1751.6 -> so of the sort of 5500 patients that had

1753.919 -> no right heart failure at three months

1756.32 -> when you looked at them at six months

1758.24 -> about you know two-thirds of them or

1759.919 -> slightly less than two-thirds of them

1761.76 -> had no episode of radar failure between

1763.679 -> three and six months

1765.44 -> whereas a small handful of patients 2.5

1769.12 -> developed

1770.159 -> mild right heart failure and 0.9 percent

1772.799 -> develop moderate right heart failure

1774.64 -> some of the other people were sort of

1776.08 -> lost to the follow-up either because

1778 -> they died or because they got

1779.36 -> transplanted or some other reason or

1781.039 -> they you know they didn't have their

1782.159 -> forms filled out

1783.52 -> so there's a handful of those patients

1785.039 -> as well but in general

1787.039 -> if you don't have right heart failure at

1789.52 -> your three month visit so again you had

1791.36 -> no episodes of right heart failure

1792.64 -> between one month and three months

1794.72 -> so you we categorized you as no right

1796.48 -> heart failure at three months at six

1798.48 -> months

1799.44 -> most those patients continue to not have

1801.44 -> right heart failure but it wasn't like

1803.679 -> it was impossible for patients to

1805.12 -> develop late right heart failure it just

1806.64 -> wasn't super common and the same thing

1809.12 -> when you go from six months to 12 months

1810.88 -> if you look at the patients who had no

1813.279 -> right heart failure at six months

1815.6 -> about

1816.64 -> you know

1817.52 -> a little over two-thirds of those

1818.96 -> patients

1820.24 -> didn't have right heart failure at 12

1822.08 -> months and a small group of patients

1823.919 -> developed an episode of mild or moderate

1825.679 -> right heart failure so while

1828.559 -> those who have no right heart failure at

1830.559 -> three months have lower incidence of

1833.2 -> death and some of the major adverse

1834.64 -> events and tend to have better renal

1836.159 -> function and there's some signs that

1838.559 -> they have better functional capacity it

1841.039 -> doesn't mean that there's zero incidence

1842.88 -> of radar failure beyond that time it

1845.039 -> still can happen it's just not super

1846.72 -> common but it's you know reasonably

1848.32 -> common and something that we need to

1849.44 -> keep an eye on

1850.96 -> so compare that to the patients you had

1852.799 -> were categorized as mild right heart

1854.48 -> failure or moderate right heart failure

1856.48 -> so on the left and panel b is is the

1858.64 -> patients who were categorized as mild

1860.399 -> right heart failure at three months and

1862.24 -> on the right and panel c is the patients

1864.159 -> who are categorized as moderate right

1865.919 -> heart failure at three months so let's

1867.84 -> go back to panel b real quickly

1870.32 -> so

1871.12 -> if you look at the

1872.399 -> 300 some patients that had mild right

1874.88 -> heart failure between one month and

1876.32 -> three months so they were categorized as

1877.84 -> having mild white heart failure at three

1879.44 -> months

1880.72 -> interestingly about half of them in six

1882.32 -> months didn't have another episode of

1883.679 -> right heart failure about a quarter of

1885.679 -> them

1886.559 -> had another episode of mild right heart

1888.08 -> failure and you can see you know a dozen

1890.399 -> or so percent of them

1891.76 -> went on to have uh

1894.24 -> excuse me i think that back about four

1895.76 -> percent of them went on to have moderate

1897.279 -> radar failure and then there was a group

1899.039 -> of patients who either died or got

1900.24 -> transplanted or were lost to fallout for

1901.919 -> some other reason

1903.279 -> so despite having mild heart rate heart

1905.2 -> failure at three months there's a big

1907.039 -> bulk of those patients won't have

1908.32 -> another episode of right heart failure

1910.32 -> at six months and of those patients who

1911.84 -> didn't have another episode of right

1913.279 -> heart failure in six months about half

1915.2 -> of them

1916.24 -> continue to not have an episode of right

1917.76 -> heart failure at 12 months so just

1919.6 -> because you had sort of an early-ish

1921.2 -> rate heart failure between one and three

1922.799 -> months that doesn't necessarily doom you

1924.88 -> to having right heart failure for the

1926.88 -> rest of the time you're on support over

1928.88 -> the course of the first 12 months of

1930.799 -> support

1931.76 -> that being said the incidence of mild

1933.36 -> and moderate right heart failure still

1935.279 -> is

1935.919 -> is much more common in this group of

1937.919 -> patients than the group of patients who

1939.519 -> didn't have right heart failure at three

1940.96 -> months and you can see some of the

1942.64 -> patients who had mild red heart failure

1945.039 -> at three months

1946.559 -> and then still had mild right heart

1948.32 -> failure at six months you know some of

1950.08 -> them went on to not have right heart

1951.519 -> failure 12 months some of them went on

1953.039 -> to have another episode of mild red

1954.48 -> heart failure some of them uh went on to

1956.64 -> having a moderate episode of right heart

1958.24 -> failure so there is a little bit of

1960.08 -> change over time and the worse your

1962.24 -> right heart failure status is at three

1963.76 -> months the more likely it is to recur in

1966.399 -> the first 12 months

1968.32 -> and then lastly in the 300 odd patients

1970.72 -> or 296 patients who had moderate right

1973.2 -> heart failure at three months which is

1974.72 -> panel c you can see it's somewhat

1977.279 -> different

1978.32 -> about a third of the patients had

1980.799 -> no right heart failure by six months

1982.799 -> about seven percent of them had an

1984 -> episode of mild right heart failure

1986 -> and about a quarter of them had another

1987.44 -> episode of moderate right heart failure

1989.679 -> so clearly the patients with higher

1991.76 -> degrees of right heart failure between

1993.76 -> one and three months

1995.36 -> are at higher risk over time for having

1997.519 -> subsequent episodes of moderate right

1999.279 -> heart failure

2000.48 -> so there is

2002 -> some trends over time that when you get

2003.76 -> to around three months

2005.6 -> you start to

2007.519 -> start to kind of call the population out

2009.84 -> into sort of a high risk group a medium

2011.519 -> risk group and a low risk group and

2013.279 -> those with who had higher degrees of

2015.2 -> right heart failure early on tend to

2016.799 -> have higher degrees of right heart

2018.08 -> failure

2019.279 -> later on those that had no right heart

2021.76 -> failure early on tend not to tend not to

2023.84 -> get it

2024.72 -> but it still can occur late even in

2026.559 -> patients who didn't have early right

2027.919 -> heart failure

2031.12 -> so i thought maybe i just sort of

2033.279 -> stopped there i have some sort of other

2035.84 -> thoughts but maybe i just kind of

2038.88 -> turn it back to the group and chat i

2040.64 -> know that kind of went through a lot in

2042 -> a relatively short period of time and so

2044.24 -> maybe i kind of throw it back to the

2045.519 -> group to to answer any questions and

2048.48 -> maybe talk a little bit more about the

2049.76 -> implications of some of the findings

2053.04 -> thank you so much i mean that was a

2054.56 -> wonderful talk and i'm sure we have a

2056.48 -> lot of interested people have some

2057.919 -> things i'd like to ask you it looks like

2059.04 -> dr bellam conda has her hand up so i'll

2060.72 -> let lobby talk first

2066.48 -> hi jeff thank you so much for coming and

2068.159 -> giving that excellent talk um a couple

2071.359 -> of questions i mean do we have a sense

2073.52 -> based off of

2075.76 -> the baseline

2077.28 -> echo or clinical parameters and then

2079.919 -> post immediately post-op prior to

2081.839 -> discharge clinical parameters as to

2084 -> there's a correlation between rv

2085.76 -> function

2087.52 -> and development of right heart failure

2089.52 -> at three months

2091.2 -> um

2092.399 -> so there is there is some um and i think

2095.2 -> that's been reported in prior in prior

2096.8 -> series when looking at sort of risk

2098.16 -> factors with with intermax

2100.4 -> the problem with intermax is it doesn't

2102 -> really have a lot of great markers um

2104.32 -> for our means we have the hemodynamics

2106.24 -> and most people have hemodynamics but

2108.8 -> they're hemodynamics on unknown levels

2110.8 -> of support right so

2112.64 -> you know the per just because someone

2113.92 -> has a radiation pressure of seven um you

2116.72 -> know might be someone with a radiation

2118 -> pressure of seven and

2119.52 -> walked in from home and is gonna get

2121.04 -> their pump the next day and their right

2122.56 -> ventricle is very good

2124.079 -> it could the same time could be someone

2125.44 -> who has a radiation pressure of seven

2127.2 -> because they're on a balloon pump and

2128.56 -> they're on lots of divitamine and maybe

2130.16 -> some dopamine and they've been in the

2131.44 -> hospital for three weeks and they go get

2133.28 -> their you know that's their last set of

2134.72 -> hemodynamics before they go get their

2136.24 -> bad

2137.28 -> so even some of those

2139.119 -> criteria even though some of those

2140.56 -> criteria are a little bit hard to

2142.56 -> interpret and then from an

2143.599 -> echocardiographic standpoint

2145.76 -> there's not a lot of great data and we

2147.359 -> have the degree of tr as reported by the

2149.2 -> centers the rv function and that's just

2151.52 -> sort of subjective

2153.119 -> mild moderate to severe

2155.28 -> but we don't have a lot of the kind of

2156.64 -> more complex

2158.48 -> tissue doppler and other techniques that

2160.48 -> people have looked at to better quantify

2163.119 -> or at least

2164.32 -> augment our ability to quantify right

2166.079 -> ventricular dysfunction so i think

2168 -> intermax

2169.04 -> although we can learn a lot from

2170.16 -> intermax i think the the

2172.72 -> kind of gory details and the grainy the

2175.119 -> more granular look at uh

2177.92 -> risk factors

2179.2 -> i think just aren't there in a max

2180.72 -> unfortunately to really say

2182.56 -> and we try and as part of this analysis

2184.24 -> we just tried to stay away from that the

2186.16 -> sort of prediction question we just said

2187.599 -> okay you got your continuous flow bad

2189.839 -> you made it to three months

2191.92 -> how are you with three months you know

2193.2 -> how are you between one and three months

2194.48 -> what was your right heart failure status

2196 -> and then try to sort of look at later

2197.599 -> episodes of right heart failure to kind

2199.119 -> of better characterize what would be

2200.88 -> what was the impact of later right heart

2202.48 -> failure but also what was the subsequent

2205.68 -> uh tempo of its development

2208.48 -> yeah thank you and i i i

2211.2 -> completely make sense and i guess the

2212.96 -> intention of that question really is

2215.04 -> um as a clinician you're wondering why

2217.44 -> suddenly someone's developing a right

2219.2 -> heart failure at three months or six

2220.88 -> months or 12 months or whatever the time

2223.119 -> time frame is right

2224.56 -> so um and again like like like you

2227.52 -> alluded to in the talk there's so many

2229.2 -> things that go into

2230.8 -> uh into causing right hex failure it

2232.8 -> could be the pump speed that's too fast

2234.88 -> and now the rb uh looks like it's it's

2237.2 -> worse and uh and the jvp is up it could

2240 -> be pump failure it could be thrombosis

2242.4 -> in the pump and it's got nothing to do

2243.92 -> with the rv it's just about especially

2245.52 -> with the way we're defining right heart

2246.88 -> failure which is elevation of jvp and

2248.88 -> edema

2249.839 -> so that's why i was asking to see if

2251.76 -> there's something wrong with the rv to

2253.839 -> begin with and if it's truly right heart

2256.24 -> failure that we're detecting or calling

2259.119 -> i mean i suspect that it is because i

2260.72 -> think a lot of those other things excuse

2262.079 -> me are relatively rare um you know

2264.48 -> particular things like you know pump

2266.079 -> thrombosis but i mean who knows how

2267.76 -> people are managing the pumps um you

2269.839 -> know my sort of only take from the

2271.28 -> hemodynamic data that's out there and a

2273.04 -> lot of this came from one year was it

2275.119 -> was in chicago

2277.119 -> was that if anything

2279.119 -> it's not so much the pump speeds are too

2280.8 -> fast as people's pump speeds are too

2282.48 -> slow um so it's not like your pumps are

2285.119 -> so fast and you're you know your

2286.64 -> quote-unquote sucking the septum over

2288.8 -> and and inducing right ventricular

2290.56 -> dysfunction it's more that you're

2292.079 -> inadequately decompressing the left

2293.52 -> ventricle and maybe sort of

2295.76 -> uh

2297.2 -> leaving a state of kind of persistently

2298.8 -> elevated afterload to the right

2300.48 -> ventricle more than anything else

2302.96 -> um but you're right i mean we don't

2304.8 -> really know um

2307.04 -> and it's i mean

2307.94 -> [Music]

2309.2 -> the definition is a little bit soft and

2311.52 -> like i said i think you can come up with

2313.04 -> lots of scenarios why someone may have

2315.76 -> elevations and manifestations of

2317.68 -> elevated cvp that aren't necessarily

2320.079 -> really

2321.52 -> a primary pathology of the right

2323.119 -> ventricle

2324.88 -> but it's kind of what we have right i

2326.24 -> mean it's it's it's

2327.68 -> it's the only only

2330 -> only way the only way to kind of look at

2331.44 -> the data because that's just the

2332.32 -> definitions that were come up with that

2333.92 -> were developed at the time

2335.68 -> yeah i mean all the limitations based on

2338.079 -> characteristics the patients who didn't

2339.92 -> have right heart failure tended to have

2341.28 -> less right ventricular dysfunction and

2342.8 -> they tend to have a lower radiation

2344.079 -> pressure and they tend to have better

2345.44 -> creatinine and

2347.04 -> so

2348.32 -> you know i think there is some

2349.52 -> circumstantial evidence that their right

2351.28 -> ventricular ventricles are probably

2352.839 -> healthier uh with the understanding that

2355.2 -> there's a lot of other factors that are

2356.4 -> involved too

2357.839 -> and last question before i let you go

2359.28 -> what what do you think what would you

2360.96 -> speculate as the etiology of the

2362.56 -> increased risk of stroke that you have

2364.56 -> coated in your central figure

2366.4 -> um the the stroke risk is significantly

2369.04 -> higher in this rv failure patients

2371.839 -> yeah i don't i mean i i think that

2374.4 -> i think that

2375.92 -> some of it may be pump management um

2377.92 -> some of it may be anticoagulation um you

2380.64 -> know we didn't uh we didn't parse out

2383.76 -> uh hemorrhagic versus thrombotic stroke

2386.079 -> um so how much of it's sort of liver

2387.68 -> congested and you know the person's a

2389.44 -> little bit more bleedy than someone who

2391.28 -> doesn't have liver congestion how much

2393.119 -> of it is uh

2396.48 -> other factors and other factors with uh

2399.28 -> you know lower pump speeds because

2401.2 -> you're worried about the rv and so you

2403.44 -> don't get as much washing and maybe the

2405.04 -> valve doesn't open up as much and you're

2407.2 -> a little bit more likely to get a stroke

2409.28 -> how much is it you have right

2410.96 -> ventricular failure and just in general

2412.88 -> you're not in as good of a shape and

2414.319 -> you're in your

2416.16 -> the balance between

2418.24 -> thrombosis and bleeding isn't

2421.44 -> as finely tuned as someone who's in much

2423.44 -> better shape and doesn't really have

2425.599 -> residual heart failure i i

2428.079 -> it could be all those things you know

2429.44 -> the inflammatory state may be better in

2431.119 -> someone who doesn't have right to heart

2432.24 -> failure than someone who has persistent

2433.92 -> low degrees of right heart failure and

2435.28 -> so they may be at higher risk of stroke

2437.76 -> uh not not sure

2440.88 -> thank you so much

2444.079 -> jeff this is tariq thank you so much for

2446.319 -> an outstanding this is uh

2448.319 -> really close to our heart because we

2450 -> think about it and so

2451.599 -> um couple questions so

2454.56 -> you know uh

2456.16 -> um

2457.599 -> a lot of people come up with

2459.68 -> you know ways to predict who's gonna

2460.88 -> have rv failure the bottom line is a lot

2462.72 -> of these patients are gonna need an lvad

2464.8 -> because they don't have any other option

2467.359 -> and we're dealing with people with

2468.64 -> biventricular failures so

2470.88 -> in your kind of you know synthesizing

2473.28 -> all the information out there and

2474.96 -> writing the paper how do you

2477.52 -> minimize the risk of rv failure

2480.8 -> in someone who's going to go through

2482.319 -> with an lvad

2483.92 -> you know to quote-unquote you know the

2485.76 -> surgeons will tell us like let's

2487.2 -> optimize this patient before

2490 -> um so what do you think should be done

2492.4 -> kind of before and then obviously

2494 -> intraop and then afterwards

2496.319 -> to reduce this risk of rv failure

2500.319 -> well i wish i knew

2502.64 -> i don't have i don't have a great answer

2504.48 -> but i i think you're right i mean i

2506 -> think that

2506.839 -> the preoperatively i mean it's better to

2509.52 -> go into the operation with

2511.599 -> decongested kidneys and decongested

2513.52 -> liver and a decongested lung and and and

2516.64 -> um

2517.839 -> you know just sort of

2519.52 -> better right heart

2521.28 -> hemodynamics

2523.359 -> at the same time

2525.2 -> i think to

2528.16 -> you know i think 10 years ago i would

2530.079 -> have probably spent another several days

2533.44 -> monkeying around to see if i could make

2535.359 -> the person's hemodynamics look better

2537.839 -> i think i'd less likely to do that now

2540.319 -> uh you know it is what it is the risk is

2542.8 -> what it is you know just take them to

2544.72 -> the operating room um because lots of

2546.96 -> bad things can happen as you kind of

2548.72 -> wait and wait and wait for the right

2549.839 -> heart numbers to look better

2550.88 -> particularly as you're escalating

2551.92 -> support because like i said earlier i i

2553.68 -> don't know what it means to have

2555.839 -> okayish right heart hemodynamics on tons

2558.319 -> and tons of support versus someone who's

2560.079 -> on less support versus someone who's on

2561.76 -> those support although i suspect that

2563.68 -> that radiation pressure of whatever you

2566.48 -> whatever value you're shooting for

2568.48 -> probably is less meaningful on someone

2570 -> who's on tons of support versus someone

2571.68 -> who's on no support whatsoever

2574.319 -> you know i think intraoperatively

2576.48 -> defer to some of my surgical colleagues

2578.24 -> in terms of

2580.8 -> the sort of you know tricks of the trade

2582.64 -> but you know the kind of getting get out

2585.359 -> um is i think there's something to be

2587.44 -> said for that because i think the longer

2588.96 -> the bypass times the more more you get

2591.04 -> into bleeding the more

2592.8 -> stuff you run into i think the bigger

2594.64 -> the problem in monitoring folks is pa

2596.96 -> pressures and right atrial pressures to

2598.72 -> make sure you're optimizing their volume

2600.48 -> status and they're not coming out with

2601.76 -> really high rate ho pressures i think

2603.28 -> are all really important

2604.8 -> and i think the same thing kind of goes

2606.48 -> in the early perioperative management as

2608.64 -> well in terms of

2610.4 -> just making sure you're getting adequate

2611.76 -> volume off and you're supporting the

2612.96 -> right ventricle uh you know you don't

2615.119 -> have to run the pump super high i think

2616.72 -> we all know that now

2618.72 -> but i think it's i think it's just sort

2620.24 -> of the small things

2622.64 -> but even amongst all that you know so if

2625.76 -> when you look at sort of all these early

2627.52 -> predictive things for rv failure

2629.839 -> is it really a bad thing let's let's say

2632.24 -> someone's at high risk for rv failure

2634.24 -> defined as the need for an arvad or 14

2636.48 -> days of vinotrops and they don't really

2638.64 -> need an arvad

2640.4 -> and it takes you

2642.24 -> 22 days to get rid of their miller known

2644.72 -> but then you get them home and they do

2645.92 -> okay that person has rv failure and

2648.079 -> you've predicted that they have rv

2649.359 -> failure but

2650.8 -> you know so what they did okay and maybe

2652.72 -> by month three they're in that

2655.28 -> no recurrent right heart failure group

2657.2 -> so i still don't think we really

2658.4 -> actually know i mean i'm not even sure

2660 -> how useful some of these things are i

2661.44 -> mean i i would like to know the people

2662.96 -> that

2664.16 -> are going to have

2665.2 -> such bad right ventricular dysfunction

2666.88 -> that they're going to need an rv and i

2668.8 -> think that's important

2670.079 -> but

2671.52 -> do we really care about the prediction

2673.359 -> of

2674 -> prolonged

2675.52 -> i i don't know you know you'd say well

2677.359 -> the person that never comes off

2679.28 -> ionotropes yes that's important and i i

2681.52 -> don't disagree with you but you know is

2683.68 -> there really

2685.2 -> something bad about that i mean some of

2686.88 -> that early inner max data would suggest

2688.4 -> that the longer you're on inotropes the

2690.319 -> more likely it is to put after the

2692.56 -> operation the more likely it is you have

2694.24 -> or to have a worse outcome but

2697.2 -> you know some of that is

2699.52 -> center preference and center styles and

2702.16 -> i i'm not just not i'm just not sure

2704.24 -> exactly what it is ultimately

2706.319 -> we're predicting and you know

2708.24 -> particularly for someone who's a bridge

2709.359 -> to transplant it

2710.64 -> maybe if they get an early rv they do

2712.64 -> okay and you explain it and their

2713.92 -> hospitalization is longer and it costs a

2715.76 -> little bit more but maybe they do okay

2717.04 -> in the long term and is that necessarily

2719.04 -> a bad outcome no not necessarily

2721.76 -> so

2723.76 -> this sort of prediction of right

2725.52 -> ventricular dysfunction i think we're

2727.04 -> still hampered a little bit by the sort

2728.72 -> of what it is that we're predicting um

2731.28 -> you know if we knew

2732.88 -> that we were predicting people who had

2735.92 -> who struggled long term those patients

2737.68 -> made with moderate right heart failure

2739.2 -> at three months that although some of

2740.96 -> them do okay over time many of them

2743.04 -> don't i think that's a little bit

2744.88 -> different of a predictor than the sort

2746.88 -> of early markers that we're

2749.119 -> currently trying to predict

2750.88 -> i mean i completely agree with you and a

2752.319 -> lot of times you know we we're uh

2754.56 -> we end up you know the treatment ends up

2756.24 -> being worse than the cure because we're

2757.76 -> trying to optimize those right atrial

2759.44 -> pressures and hemodynamics and there you

2762.24 -> know some some people even believe in

2763.839 -> putting a balloon pump before

2766 -> um and

2767.28 -> i personally think i mean the ionotropes

2768.88 -> might make the numbers look better but i

2770.72 -> don't know how good it is to to be

2772.48 -> flogging the heart for that long before

2775.2 -> uh before doing something and then the

2777.2 -> other thing is like the post-operative

2778.56 -> management seems to be kind of all over

2780.079 -> the place as well uh some people might

2782.319 -> respond by saying okay there's high-risk

2784.319 -> for rv failure so just let's put in an

2786.4 -> rv support device early

2788.8 -> and some people will write it out i mean

2790.24 -> i don't even know what the right answer

2791.68 -> is and

2792.64 -> um

2793.52 -> i don't know if you have experience with

2795.04 -> that i mean

2796.16 -> i've been getting texts from the

2797.359 -> surgeons right now because we've got you

2799.28 -> know several patients like waiting for

2800.96 -> lvats with with rv failure to start off

2804.4 -> with and they're like well what should

2805.92 -> we do you know before and after to prep

2808.8 -> for this kind of high risk

2811.2 -> and

2812.16 -> yeah

2813.119 -> i don't know what the right answer is

2814.24 -> you know like i mean should we just do a

2815.599 -> protag duo uh prophylactically like

2818.48 -> should we

2819.68 -> just started you know try to

2821.119 -> aggressively diarrhea afterwards or just

2823.28 -> do high dose cyanotropes and you know

2825.28 -> inhale nitric oxide it just seems like a

2826.96 -> little bit

2828 -> um

2828.96 -> that everyone's got a different answer

2830.56 -> that they they feel very strongly about

2833.599 -> yeah i mean i think there's a lot of

2834.64 -> home cooking um and and i think that's

2836.72 -> that way because there's just not a lot

2838 -> of evidence um you know i it's my sort

2840.16 -> of chicken soup analogy that i think

2842.4 -> everybody has their own sort of recipes

2844.72 -> for chicken soup and you think yours

2846.16 -> tastes better than everybody else's and

2848.319 -> the ingredients are basically the same

2850.16 -> everywhere except you know you have your

2851.599 -> little secret right heart failure

2852.72 -> ingredient and other patients have

2854.079 -> places have their secret regard failure

2856.8 -> ingredient but in the end it's still it

2858.96 -> is what it is and so i i i try not to i

2862.64 -> guess i try not to

2865.359 -> discount what can happen in the

2866.72 -> operating room in that

2868.4 -> you know like like i said earlier i

2870 -> think you could take someone with them

2871.28 -> whose rv looks marginal and has criteria

2875.2 -> which would mark it as marginal and they

2877.28 -> could do very well in the operating room

2878.96 -> and not have any problem at all and so

2881.92 -> rather than say okay this person doesn't

2884.48 -> look you know the right ventricle

2886.4 -> doesn't look good and they're

2888.16 -> higher risk for rv failure by and saying

2890.559 -> we're just going to preemptively put

2892.079 -> some sort of

2893.359 -> temporary right for particular

2895.04 -> mechanical support in them

2896.88 -> i don't know i don't know that's needed

2898.48 -> i mean i think you have to sort of let

2900 -> the orf play itself out and you know

2902.16 -> conversely someone who doesn't look like

2904.079 -> they have a bad right ventricle but you

2906.16 -> know bad things happen in the operating

2908.24 -> room it's not like you should rest on

2910.559 -> the fact that oh the person's rv was

2912.079 -> normal going in so i'm not going to

2913.28 -> worry about their ventricle now i'm not

2915.44 -> suggesting that people wouldn't worry

2916.559 -> about it but it's more just sort of kind

2918.4 -> of

2921.2 -> i think if someone's at high risk being

2922.96 -> a little bit maybe more meticulous and

2925.119 -> being a little bit more careful but you

2926.839 -> know that's not always the doesn't mean

2929.839 -> something bad is not going to happen and

2931.359 -> i guess the biggest thing is if it looks

2932.8 -> like the person's struggling to get out

2934.079 -> of the operating room i'd much rather

2936.16 -> have them come out with an rvd than

2938.48 -> than

2939.28 -> rocket fuel because 48 hours later their

2941.599 -> kidneys don't work and their liver

2942.8 -> doesn't work and they're vasoplegic and

2944.96 -> then they sort of die is cast and it's

2947.44 -> hard to get those people back

2952.319 -> thanks so much jeff that's that's really

2954.079 -> actually very helpful because

2956.079 -> i feel like it's very unsatisfying

2957.599 -> because i mean we have the same

2958.4 -> conversations amongst all of us and i

2960.16 -> think it's just

2961.52 -> you know i try not to get too fixated on

2964.64 -> on

2966.72 -> kind of moderate amounts of right

2968 -> ventricular dysfunction you know it's

2970.559 -> it's kind of one of those things you

2971.68 -> sort of overall look at look at the

2973.44 -> person look at where you're trying to

2974.72 -> accomplish they dt or they beat tt

2976.72 -> although if you were fewer people or btt

2979.359 -> you know what's the rest of their organs

2980.8 -> look like are their kidneys marginal and

2982.88 -> they're not going to tolerate much of an

2984.079 -> rv insult or they have a robust kidney

2985.92 -> reserve and you know they could tolerate

2988 -> a little bit of rv insult but they have

2989.839 -> multiple time re-up

2991.52 -> are they going to need a lot of rehab

2993.68 -> you know and try and kind of put it all

2995.04 -> together into into the sort of

2996.88 -> assessment of risk and then

2998.559 -> go for it and recognize that the

3000.48 -> person's rv doesn't work very well and

3002.72 -> try and be as meticulous as you can in

3004.16 -> your care afterwards

3013.599 -> maybe i can ask you guys a question so

3015.04 -> from

3016.16 -> are there things that you guys do or

3018.24 -> there

3019.2 -> are there

3020.96 -> techniques styles approaches either in

3024.319 -> the operating room beforehand afterwards

3026.48 -> for patients who you have concerns about

3028.48 -> right ventricular dysfunction i'm always

3029.839 -> curious what other people are doing

3031.119 -> because

3032.079 -> like i said i fully admit that i don't

3033.68 -> have all the answers

3035.2 -> we drive the ccu uh

3037.92 -> nursing staff crazy because every

3039.68 -> attendant has a different way of doing

3041.28 -> it

3043.52 -> our surgeons blame us for not optimizing

3046.16 -> the patient enough prior to surgery i

3048 -> don't know if you guys have anything

3049.2 -> wrong

3050.96 -> [Music]

3052.24 -> i mean i think that i think one of the

3054 -> things that the that

3056.319 -> yeah i think both the pittsburgh and

3058.559 -> here

3060.079 -> i think we've maintained pretty open

3061.76 -> lines of communication for people who

3063.28 -> are sort of marginal

3064.72 -> and

3066.079 -> and to not get kind of caught up in the

3067.68 -> one more day one more day one more day

3069.44 -> thing and you know just i i talked you

3072.4 -> know we tried to talk with the surgeons

3074.16 -> when we think that the person's going

3075.839 -> every day and say

3077.119 -> here's what here's what we did over the

3078.48 -> last 24 hours is this person any better

3080.64 -> or not then she would just take him to

3082.079 -> the or now and the surgeon's like well

3084.079 -> you know give him one more day or try

3085.359 -> and get a little bit more volume off and

3086.88 -> you know the next day you say i tried

3088.319 -> and nothing worked

3090 -> and then i think everybody kind of knows

3091.44 -> what they're getting when they roll into

3093.44 -> the operating room

3096.319 -> arnold patrick muhammad you guys are the

3098.64 -> you know the men in the arena what do

3100.4 -> you guys think

3109.599 -> sorry derek um

3113.44 -> very interesting talk um

3115.76 -> you know um

3118.64 -> you know it's challenging i know you

3120.4 -> know it's how exactly how to manage some

3122.559 -> of the stuff and you know i think it's

3124.079 -> very i mean we try to manage these

3127.04 -> people together and uh discuss it but

3130.88 -> i think it's a

3132.96 -> very thoughtful discussion i don't have

3134.88 -> any specific comments you know how do

3136.88 -> you mean it's because i think it's you

3138.079 -> have to go by case by case basis

3144 -> i think that it's it's

3147.119 -> i think we all expected we would see

3148.72 -> late right heart failure and again we

3150 -> can argue about sort of what it means to

3151.599 -> be late right heart failure and what

3152.8 -> time frames and how severe

3155.2 -> but

3157.28 -> it was still surprising that there's you

3159.359 -> know

3160.079 -> one out of 10 patients who don't have

3161.599 -> right heart failure at three months

3164.24 -> get it some other time in the first 12

3166 -> months or the remainder of the their

3168.16 -> nine months on support over the first

3169.839 -> year

3170.8 -> so

3172.079 -> it can still happen um the question sort

3174.319 -> of why is it happening in those patients

3175.92 -> is that our fault because of inadequate

3177.599 -> diuresis because of improper pump

3179.359 -> management or is it just because of sort

3181.599 -> of the progression of the pathology of

3183.44 -> the right ventricle or some combination

3185.2 -> of all those sorts of things

3187.119 -> and and i think it was also

3189.28 -> a little sobering to see that at three

3191.599 -> months if you were categorized as having

3194 -> more moderate degrees of right heart

3195.359 -> failure

3196.64 -> it recurred a lot and had a really big

3198.319 -> impact on adverse events um and so

3201.359 -> you know the question is who are these

3202.96 -> people that have moderate degrees of

3204.48 -> right heart failure at three months the

3206.319 -> good news was when you looked at the

3207.92 -> total number of patients they were

3209.119 -> implanted not that many people were

3210.72 -> categorized that way

3212.24 -> of the you know 6 000 odd patients about

3214.96 -> 300 of them were

3216.559 -> so

3217.28 -> i mean i think it could be sort of a

3218.319 -> glass half full and say hey you know

3220.319 -> that's a lot of patients who survive the

3222.319 -> three months who

3224.48 -> don't you know don't end up having

3227.359 -> more than mild right heart failure and

3228.8 -> they tend to do okay over time

3230.72 -> you know the glass half empty is that

3232.8 -> boy even people who do really well at

3234.4 -> three months can still develop mild to

3236.079 -> moderate right heart failure

3238.16 -> in the next nine months and

3241.28 -> and that could probably impact their

3243.599 -> incidence of other adverse events so

3245.92 -> i think you can look at it both ways but

3247.599 -> i think it was it was it was sobering

3249.359 -> that the patients who had moderate

3251.28 -> degrees of heart failure did so much

3253.44 -> worse

3259.28 -> it's interesting also sometimes you do

3261.04 -> cases that

3262.72 -> you expect a bad right here for you they

3264.559 -> do fine and you know why is that

3266.4 -> sometimes i mean another very

3268.079 -> interesting you know teenagers you know

3270.64 -> we've done two or three teenagers

3272.48 -> without that

3274.88 -> one wesley we were convinced we needed

3276.88 -> our ad no problem and they tend not to

3279.76 -> require you know and you know recover i

3282.079 -> mean obviously different pathology but

3283.68 -> still

3284.48 -> you know why would that be so different

3286.16 -> than the adults

3288 -> yeah i mean it's it's you know it's sort

3289.52 -> of why do they have right failure right

3291.28 -> does someone have right heart failure

3292.559 -> because they have really bad mr and

3294 -> lmbpa pressures and really bad afterload

3297.68 -> and when you totally unload them they do

3300.079 -> really well or do they have rb failure

3302.079 -> because they just have some sort of

3303.28 -> really that really advanced right

3305.28 -> ventricular myopathy and it doesn't

3307.44 -> matter how much you unload them

3309.76 -> the right ventricles just don't work um

3312.079 -> and i don't think we can i don't think

3313.52 -> we can

3314.559 -> parse out those phenotypes either

3318.4 -> so after you know

3320.4 -> 10 or 15 years of looking at this and

3322.319 -> doing this

3323.76 -> i don't know a whole lot more than i did

3325.119 -> when i first started we have some data

3327.04 -> to sort of characterize the incidence of

3329.2 -> these things but i think we're i think

3331.119 -> we all still struggle uh to to risk

3335.2 -> stratify

3336.48 -> but

3337.2 -> sometimes i feel like we get a little

3338.64 -> bit too caught up in

3341.839 -> in in

3343.2 -> predicting something

3345.04 -> rather than just sort of putting in kind

3347.28 -> of the

3349.04 -> calculator of

3351.119 -> of how much overall badness will this

3353.52 -> person have and making making a more

3356 -> holistic decision and not being super

3358.079 -> hyper focused on the person's right

3359.44 -> ventricle

3366.559 -> so now we're coming to the top of the

3368 -> hour so i don't know if anybody has any

3369.68 -> last questions for dr teuterberg

3376.24 -> actually jeff i have uh one kind of

3378 -> logistic question and you've been

3380 -> involved with my shlt and

3383.04 -> you know

3384.079 -> we got a hold of the intermax data from

3387.2 -> from biolink but it stopped in 2017 and

3390.72 -> there's a lot to be said about being

3392.72 -> able to have access to

3394.64 -> you know the heartmate 3 data the the

3396.64 -> most uh most recent data do you think

3399.359 -> that the um

3402 -> you know the ichlt or maybe these uh

3405.04 -> kind of these groups would be would be

3407.04 -> uh you know interested in in helping

3409.599 -> that data be available like it was so

3412.48 -> that we can

3413.76 -> you know gain insight from it because

3415.599 -> it's now close to impossible to get

3417.599 -> access to it again

3419.359 -> um which is kind of unfortunate because

3422.16 -> i think the the papers were adding a lot

3424.799 -> to our management decision making

3428.559 -> yeah i know i i don't disagree um there

3431.28 -> was a lot of

3432.88 -> i spent a lot of my

3434.799 -> sort of

3435.68 -> president-elect and president presidency

3437.839 -> of the ice held it kind of dealing with

3439.839 -> the migration of

3441.44 -> intermax from the nhlbi to the sts

3445.119 -> and it's not as if the

3447.839 -> ice hlt didn't have interest in

3449.55 -> [Music]

3452.48 -> you know taking over quote unquote the

3455.359 -> intermax database

3458.16 -> nhlbi i think wanted to see

3462.48 -> wanted to see the database survive and

3466 -> be used in a way that

3468.21 -> [Music]

3470.96 -> could help

3474.319 -> payers and centers sort of even patients

3476.319 -> could have understand

3478.16 -> the the

3481.44 -> sort of lay of the land

3483.04 -> and they felt that sts was better

3485.52 -> positioned because of the database that

3487.92 -> they they had even though their

3489.2 -> databases typically went to 30-day

3490.96 -> outcomes that they had the sort of

3492.799 -> already the existing infrastructure to

3494.64 -> be able to better support that um and so

3497.28 -> ultimately that's why they chose the sds

3500 -> matter of fact they i think they just

3501.92 -> mostly went to the sts and we weren't

3504 -> even sort of given the offer right of

3505.599 -> first refusal

3507.04 -> so there's a very complex political

3509.119 -> issue and sort of and that that's i'm

3511.52 -> not blaming the nhlbi i think that there

3513.28 -> are good reasons for it to go to the sts

3514.96 -> too but

3516.88 -> that being said i think that the sort of

3519.04 -> closer working relationship that is hlt

3521.52 -> used to have with those who are running

3523.04 -> intermax although i still exist in sort

3524.88 -> of a collegial fashion the

3527.68 -> you know you have to go like you said

3528.72 -> you have to go through the sts i think

3531.28 -> in the near future i think there's very

3532.799 -> little chance that there will be open

3534.319 -> access to the sts intermax database it's

3537.52 -> it's you know it's kind of part of their

3538.88 -> business model and it's not that they're

3540.64 -> purely making money off of it but you

3542.4 -> know they

3543.28 -> it's a resource to them and they pay a

3545.04 -> lot to maintain it and to improve it and

3548.559 -> so you know

3550.319 -> i think that in its current iteration

3553.04 -> there won't be open access i mean there

3554.72 -> is access to it in terms of how you

3556.4 -> apply but it costs money

3558.51 -> [Music]

3559.92 -> the other thing that we have sort of

3561.839 -> floating around in the background is

3563.2 -> that the sds has involved heart failure

3565.2 -> cardiologists and their sts working

3567.119 -> group

3568.079 -> have the fortunate

3569.76 -> opportunity to kind of be part of that

3571.599 -> there's also an rv

3573.28 -> task force that's part of

3575.92 -> intermacs that we have the ability to

3577.52 -> ask for data and do

3579.839 -> do research studies and this is this is

3582.24 -> one of the studies that kind of came out

3583.68 -> of that working group

3585.359 -> so that

3586.64 -> we can hopefully respond to the

3588.16 -> community's

3590.64 -> interests and don't have to wait for

3592.11 -> [Music]

3593.68 -> people just

3594.799 -> to

3596.799 -> to

3597.599 -> apply to get data for specific research

3599.68 -> interests we can kind of keep pushing

3601.359 -> the rv

3602.4 -> the rv issue and publish data and try to

3606.319 -> meet the community's needs and

3607.599 -> understand the community's needs and do

3609.119 -> research studies that reflect those

3610.96 -> needs

3612 -> so

3612.799 -> it's kind of a long-winded way of saying

3614.4 -> i don't think that there'll be an

3615.359 -> opportunity to have open access to the

3617.28 -> sds

3619.04 -> intermax database anytime soon but i

3621.44 -> hope i hope that there are methods out

3623.28 -> there to respond to the community's

3624.96 -> needs for more information

3627.2 -> so it's gonna it is what it is for the

3628.559 -> time being i think thank you so much i

3630.319 -> mean i

3632.72 -> really appreciate

3634.16 -> um

3635.52 -> you're trying to get trying to get

3637.76 -> you know

3638.64 -> global access but absolutely

3640.559 -> if anyone else has any

3642.4 -> this was really really really helpful i

3644.4 -> mean again

3645.68 -> we we've been talking about this every

3647.44 -> day this last week so

3650.24 -> all right well like i said i really

3651.599 -> appreciate you guys uh inviting me to

3653.52 -> chat with you today if you have any

3654.559 -> questions please feel free to reach out

3655.92 -> anytime uh you know email me call me i'm

3658.72 -> happy to chat offline anytime

3665.119 -> jeff before you leave i just had one

3666.799 -> quick question for you sure um

3668.88 -> what's happened to uh the mix between

3671.2 -> lvads and transplants that stand for the

3674 -> last minute you guys

3675.68 -> uh what's the kind of ratio now for for

3678.72 -> for your practice

3680.64 -> yeah we're essentially doing zero bridge

3682.48 -> to transplant bads

3685.119 -> uh you know it's almost every bad now is

3687.04 -> dt

3687.92 -> um and our numbers of

3690.079 -> our bad numbers are picking back up but

3691.92 -> they were cut over over half

3694.64 -> okay

3695.44 -> so i mean we're you know we did sort of

3698.64 -> 30 bads last year and

3700.559 -> over 100 hearts so you know it's our

3703.2 -> heart numbers keep going up and our bad

3705.76 -> numbers took a huge hit around the

3707.599 -> around the

3708.96 -> allocations time you know for good

3711.359 -> reasons we could get people transplanted

3712.799 -> really quickly but essentially everybody

3714.88 -> is dt now

3716.88 -> thank you so much this is really helpful

3719.2 -> thank you very much hope everything's

3720.48 -> well with you

3721.52 -> thanks thanks guys appreciate it have a

3722.96 -> good one

Source: https://www.youtube.com/watch?v=8OaODDHfKkI