Heart Failure: What it Means and the Many Effective Treatments Now Available

Aug 26, 2023

Heart Failure: What it Means and the Many Effective Treatments Now Available

What role do genetics, diet, exercise and cholesterol play in preventing and treating diseases of the heart? And what is heart failure? In this UCSF program, Dr. Liviu Klein explains why heart failure is a complex clinical syndrome, and how to treat the condition. Recorded on 11/08/2022. [1/2023] [Show ID: 38485]

00:00 Start
02:00 Main Presentation
53:14 Q\u0026A

Please Note: Knowledge about health and medicine is constantly evolving. This information may become out of date.

More from: Heart Health: Advances in Preventing and Treating Heart Disease
(https://www.uctv.tv/minimed-heart-health)

Explore More Health \u0026 Medicine on UCTV
(https://www.uctv.tv/health)
UCTV features the latest in health and medicine from University of California medical schools. Find the information you need on cancer, transplantation, obesity, disease and much more.

UCTV is the broadcast and online media platform of the University of California, featuring programming from its ten campuses, three national labs and affiliated research institutions. UCTV explores a broad spectrum of subjects for a general audience, including science, health and medicine, public affairs, humanities, arts and music, business, education, and agriculture. Launched in January 2000, UCTV embraces the core missions of the University of California — teaching, research, and public service – by providing quality, in-depth television far beyond the campus borders to inquisitive viewers around the world.
(https://www.uctv.tv)

Content

14.6 -> [MUSIC] It's my pleasure to introduce

17.25 -> my friend and colleague,

18.585 -> Dr. Liviu Klein,

20.46 -> who earned a medical degree at

22.5 -> the Carol Davila University of

24.33 -> Medicine in Bucharest, Romania.

26.805 -> He then earned a Master's of Science degree

30.8 -> in Clinical Investigation at Northwestern,

33.26 -> where he also completed

34.61 -> a residency internal medicine in

37.37 -> that area at the Advocate Illinois

38.96 -> Masonic Medical Center in Chicago.

41.03 -> Then came back to Northwestern for

44.3 -> a fellowship in cardiovascular epidemiology.

48.9 -> Also, at Northwestern's McGaw Medical Center,

51.14 -> he completed fellowships in cardiovascular disease,

53.78 -> advanced heart failure, heart transplantation,

57.245 -> and clinical cardiac electrophysiology.

59.91 -> He's a rare gem with

63.305 -> really this multi-disciplinary training within cardiology

67.07 -> and representing multiple subspecialties.

71.105 -> We're very fortunate now to have him at UCSF where

75.5 -> he is the Director of

76.97 -> the Advanced Heart Failure Comprehensive Care Center,

79.55 -> as well as the Director of

81.53 -> the Mechanical Circulatory Support Program.

84.83 -> He specializes in treating

86.51 -> patients with heart failure and arrhythmias,

88.714 -> including care before and after

91.25 -> surgery for those receiving heart transplants.

94.46 -> Together with colleagues in

96.89 -> the Department of Bioengineering

99.11 -> and Therapeutic Sciences,

100.24 -> he is also developing new technologies for

103.43 -> monitoring and treating patients with heart failure

105.5 -> and other kinds of heart disease,

107.81 -> including those with ventricular assist devices.

111.185 -> He's published more than 100 peer

113.05 -> review articles and books.

115.465 -> With that, I will turn it over to Dr. Klein. Thank you.

119.945 -> Thank you so much, Greg. It's great to be here.

124.22 -> I'm really excited to talk to you about the heart failure

128.53 -> or the path from failure to recovery.

133.77 -> Thankfully, we have so many effective treatments

137.485 -> nowadays as Greg has mentioned.

139.28 -> I'd like to share them with you.

141.79 -> But first, what is heart failure?

144.385 -> Well, it is very different than

146.89 -> other things that we have in

148.33 -> cardiology such as high blood pressure,

150.085 -> or heart attacks, or those are just diseases.

153.445 -> Heart failure is really a complex clinical syndrome,

156.175 -> that can result from many structural or

158.32 -> functional problems to the heart.

161.49 -> But basically, those problems can impair

164.2 -> the heart or the left

165.4 -> ventricle to either fill with blood,

167.83 -> and we call that diastolic problem or

170.11 -> diastolic heart failure, or eject blood.

173.22 -> We call that systolic problem or systolic heart failure.

176.68 -> As a result, the pressures in

178.87 -> the heart on the left side of the heart increase,

180.81 -> and the normal pressure,

182.35 -> it's about 12 millimeters of mercury.

184.69 -> Those pressures increase over 50 millimeters of

187.21 -> mercury and the patient start to develop symptoms.

190.355 -> Sometimes the ejection fraction,

192.22 -> which is the amount of blood that is pushed out from

195.82 -> the hear and the amount of blood that remains in

197.9 -> the heart can be normal or low.

200.36 -> If is normal, we call that heart failure with

202.49 -> preserved ejection fraction or diastolic heart failure.

206.24 -> If it is low, we call that heart failure systolic

208.744 -> ejection fraction with reduced ejection fraction

211.43 -> or systolic heart failure.

213.155 -> Heart failure can really be caused

215.165 -> by a variety of reasons.

216.68 -> Most commonly in the western world,

218.33 -> it's called the artery disease and hypertension.

221.21 -> Those are the two most common reasons

222.71 -> why patients will develop

223.94 -> heart failure if those go on for a long time.

227.05 -> Atrial fibrillation or valvular disease

229.71 -> are other causes of heart failure.

231.81 -> Eventually, patients who have diabetes,

234.41 -> if it gets uncontrolled for a long time,

237.14 -> can get to heart failure.

238.88 -> There's a growing group of

240.38 -> patients who may develop heart failure,

242.24 -> patients who have the so-called cardiomyopathic factors,

245.12 -> which are patients who undergo chemotherapy for cancers.

248.51 -> Some of those chemotherapies can

250.34 -> lead to heart failure over time.

252.74 -> That's why it's very important for us to

254.795 -> monitor those patients and monitor their heart function.

258.02 -> Eventually, all these factors over many years can

261.65 -> lead to injury of the left

263.6 -> ventricle to the left side of the heart,

265.775 -> sometimes to the right side of the heart.

268.07 -> Some patients will have

269.54 -> a decrease in the ejection fraction,

271.19 -> so the amount of blood that

272.27 -> comes out of the heart will be low,

274.12 -> and all these patients will have

275.825 -> a remodeling of the heart.

277.985 -> The normal heart will start to become

280.37 -> dysfunctional and if untreated,

283.22 -> some patients will eventually die from heart failure.

286.285 -> The most known reason

289.13 -> for heart failure in the past used to be

290.915 -> heart attacks when patients were presented to

292.85 -> the hospital probably or

294.02 -> possibly late after they've had a heart attack,

296.205 -> and then the initial infarct as you can see here in

298.82 -> this picture started to spread,

302.885 -> this function of the myocardium

304.88 -> of the heart muscle started to spread.

306.755 -> Eventually in a few hours,

308.99 -> the infarct was expanding

310.64 -> and it would lead to global remodeling,

313.25 -> by lactation of the heart increasing in bigger size.

316.915 -> Fortunately, we have a lot of new technologies now

320.04 -> where patients get to the hospital

323.06 -> very quickly and they are able to go to

325.01 -> the cardiac catheterization lab and then get stents

327.92 -> placed during their heart attack

330.94 -> which will save a lot of

332.15 -> the hormones, a lot of the myocardium.

333.965 -> We don't see a lot of patients with

336.29 -> remodeling after infarction anymore.

338.855 -> The second reason why patients may

341.36 -> have heart failure I mentioned it's high blood pressures

343.7 -> is uncontrolled high blood pressure over a long period of

346.055 -> time leads to a weakening of the heart muscle,

348.875 -> the muscle becomes hypertrophic.

352.45 -> Since the blood pressure is really high,

354.785 -> the heart has to accommodate and the muscle has

358.76 -> to increase in size

360.77 -> in order to push against that high blood pressure.

363.11 -> Similarly, when patients have already used

365.72 -> the extra amount of blood

367.46 -> in the heart because of leakage,

369.44 -> for instance, leads to an increase in

372.26 -> the heart muscle and that muscle becomes hypertrophied.

375.65 -> Eventually over time, the heart muscle cannot

379.16 -> cope with its increased afterload and starts to dilate.

383.12 -> The heart becomes dilated.

385.085 -> Essentially from a normal heart,

387.65 -> we can get both two types of dilation,

390.98 -> volume overload and the heart become

392.63 -> very dilated and pressure

394.55 -> overloaded and the heart muscle

395.9 -> becomes thick and eventually will dilate.

398.375 -> They both have a lot of common mechanisms.

400.85 -> A lot of genes get turned on in

403.59 -> the heart and a lot of muscle cells.

406.925 -> The proteins in the muscle cells become abnormal and

411.14 -> eventually leads to remodeling or pathologic shape.

416.445 -> Just want to show for example

418.11 -> a patient who received a heart transplant.

419.88 -> You can appreciate the heart in

421.98 -> the normal size fitting the surgeon's hand.

425.01 -> Then this is the heart that came out of that patient.

428.44 -> You can appreciate the pictures

430.4 -> are actually same magnification.

433.59 -> You can see that the diseased heart

435.585 -> is probably two-and-a-half,

436.74 -> three folds larger than the normal heart.

439.89 -> Then you can appreciate is

441.57 -> gray area here where the patient had a new park.

444.785 -> Clearly the heart becomes very abnormal.

448.91 -> How does the syndrome progress over time?

453.345 -> Essentially, we start with somebody that is

455.1 -> normal they have no symptoms,

456.809 -> they have normal exercise capacity.

458.61 -> If we measure their heart function

460.23 -> with an echocardiogram, for instance,

461.94 -> it looks normal and then at some point,

464.535 -> a clinical event happens.

466.26 -> Again, maybe a heart attack,

467.865 -> maybe years of uncontrolled hypertension.

470.235 -> At that point, the patient's heart

472.41 -> starts to remodel, becomes abnormal.

474.645 -> Initially, patients will have what they call

476.895 -> asymptomatic left ventricular dysfunction,

479.115 -> which means that if we would do an echocardiogram

481.56 -> randomly without a patient having any symptoms,

484.485 -> we will note that the heart is abnormal.

487.29 -> However, when we query the patient,

489.51 -> there's no exercise intolerance.

491.61 -> Patients can function normally, can go to the gym,

493.83 -> can perform these activities without any symptoms.

497.01 -> That's the stage of compensation

499.095 -> or asymptomatic LV dysfunction.

501.54 -> Again with augment medications,

503.925 -> the progression of the disease

505.56 -> continues and patients eventually will develop symptoms.

508.77 -> The two main symptoms of

510.555 -> heart failure are really what we call shortness of

512.67 -> breath or dyspnea and fatigue so patients

515.43 -> become very tired which may limit the exercise tolerance.

519.21 -> Due to these changes in their heart function,

521.925 -> a lot of hormones are produced in the body.

524.94 -> The heart is really related to

527.82 -> the kidneys in order to eliminate a lot of the fluids

530.91 -> so the kidneys now start to retain

532.62 -> salt fluids and patients

534.93 -> start to develop pulmonary

535.95 -> congestion or peripheral edema,

537.48 -> so swelling, and weight gain due to fluid accumulation.

541.26 -> Now both abnormalities can impair the functional capacity

544.86 -> and some patients may be just short

546.39 -> of breath or have fluid retention,

548.04 -> Some patients may be be fatigued,

549.78 -> some may have all these symptoms.

551.37 -> So it's not necessarily for all of those

552.87 -> to appear at the same time in all the patients,

555.825 -> at least in the initial stages.

558.735 -> It used to be that we call the heart failure,

562.71 -> congestive heart failure because it was thought that

565.08 -> all the patients will retain fluid and become congested.

568.365 -> We now know that that's not the case.

570.36 -> The term congestive heart failure

572.82 -> has been replaced just by heart failure.

575.1 -> As I mentioned initially,

576.96 -> patients when they start to become

578.55 -> symptomatic, they are compensated.

580.665 -> They still have a fairly normal excess capacity.

584.325 -> They could go to do their activities of

587.16 -> daily living but if you put them on a stress test,

590.22 -> for instance, on a treadmill and perform a stress test,

592.65 -> they will have an abnormal excess capacity

594.81 -> compared to the same age.

597.02 -> Again, if you look at the echocardiograms,

599 -> the heart function will be abnormal.

601.19 -> Eventually without treatment,

603.275 -> the heart starts to get worse and the patient starts

606.23 -> with the competency so they become symptomatic even

609.23 -> with regular activities going

611.93 -> upstairs or walking a couple of blocks,

614.345 -> they'll start to have symptoms of shortness of breath.

619.73 -> The excess capacity will be even

622.35 -> further decreased in these patients.

624.165 -> Again, if we do another cardiac performance stress test

626.52 -> or regular stress test we'll see

628.38 -> that the mutations become more

630.12 -> profound and the heart function

632.07 -> becomes even more abnormal.

634.05 -> Again, some of these patients, even despite treatment,

637.815 -> will become refractory or as we call it

640.35 -> advanced or end-stage heart failure where

643.17 -> despite all the medications and the devices that we have,

646.47 -> we can not control their symptoms and they will have to

649.23 -> be evaluated if they

651.48 -> qualify for a heart transplant, for instance.

654.09 -> Now you may have read or may have heard

656.31 -> about classification of heart failure in

658.89 -> terms like newer heart functional class

660.93 -> or stages or maybe when you go to

662.91 -> your physicians now you can read the notes and you can

665.04 -> see some of those terms in the notes.

667.41 -> I'd like to explain what they mean.

669.42 -> We have a staging system for heart failure,

673.215 -> really to alert the primary

675.27 -> care provider and the patient that

676.77 -> there are conditions which if they are untreated,

679.785 -> can lead to heart failure,

680.82 -> so we call those Stage A.

683.13 -> This is really patient's at risk for heart failure.

685.92 -> They could have coronary artery disease, diabetes,

688.56 -> high blood pressure or valvular

689.82 -> disease, atrial fibrillation,

691.35 -> and we know if those conditions are untreated eventually

694.44 -> the heart function will deteriorate and

696.18 -> patients will develop heart failure.

698.685 -> Then we have Stage B,

700.44 -> which is patients who already

701.91 -> have an abnormal heart function.

703.785 -> Again, if you randomly get an echocardiogram,

706.605 -> you can see that the heart function is abnormal,

708.78 -> but the patients don't really have any symptoms.

711.16 -> Then we have Stage C,

712.635 -> which are symptomatic patients.

714.21 -> Patients who have a formal diagnosis of

716.385 -> heart failure and they start to have symptoms.

719.19 -> Those patients in Stage C,

721.305 -> we try to classify how

722.88 -> symptomatic they are based on their activities.

725.55 -> Then we have the New York functional classification,

728.37 -> which is Class 1 to Class 4.

730.275 -> Class 1 is someone that really has

732.45 -> no limitation on ordinary activities.

734.76 -> However, if you do a stress test,

736.53 -> the formal stress test, they will be limited.

738.765 -> But in the day to day life they have no limitations.

741.63 -> Class 2 are patients who have

743.34 -> just slight limitations to physical activity.

745.275 -> Maybe they can go up three flights of stairs,

747.375 -> but then they will have to rest or

750.135 -> maybe they can carry groceries for a couple of blocks,

752.91 -> but they'll have to rest.

754.425 -> Class 3 which is most of the patients that I see in

757.5 -> my practice are patients who are remarkably limited.

760.2 -> They can maybe perform

761.94 -> some basic activities of daily living,

764.61 -> they can shower, they can cook,

766.41 -> they can clean the house,

768.42 -> but then they walk outside for a couple of blocks,

770.61 -> they'll be muchly limited or if they

772.05 -> walk up a flight of stairs.

774.195 -> Then we have the Class 4 patients who are really limited

777.93 -> even by sitting in a chair or sitting on a couch,

781.65 -> they will get short of breath and

782.96 -> they will get short of breath at night.

784.635 -> A lot of those patients are what we call Stage D,

787.8 -> so advanced end-stage heart failure.

790.32 -> Those are then patients that we would evaluate

792.885 -> for heart transplantation, for instance.

796.4 -> Just to recap what

800.16 -> we've talked about is really the heart muscle it's either

803.28 -> weakened or stiff so there's

805.02 -> a dysfunction of pushing out of luck or

807.39 -> reduced ejection fraction of systolic dysfunction so

809.97 -> the muscle is weak or a dysfunction

812.58 -> of how much the heart is

815.22 -> able to relax so the heart becomes stiff.

817.935 -> That's heart failure with preserved

819.48 -> ejection fractional burst on the heart failure.

822.045 -> As a result of either one of those,

824.13 -> the pressures in the heart increase then you have

827.37 -> leakage in the valve and

828.51 -> the mitral valve and eventually,

830.82 -> we have high pressures in your left atrium,

832.83 -> the top left chamber,

834.555 -> which will back up fluid in

836.7 -> the lungs and patients will start to become

839.595 -> short of breath because the heart is not able

842.595 -> to pushing up towards the rest of the body,

846.24 -> the patients will start to have muscle issues and

850.02 -> their skeletal muscles will

852.33 -> become very weak so they will experience fatigue.

856.155 -> There'll be tired, there'll be short of breath.

858.435 -> Again due to the kidney activation,

861.03 -> they'll start to retain fluid

862.29 -> so they'll have leg swelling,

863.49 -> they'll have abdominal swelling.

865.29 -> When the fluid goes in their lungs they will

867.6 -> have a lot of coughs as a result of

870.3 -> fluid accumulation in the lungs and then

872.7 -> all the symptoms will eventually progress.

876.239 -> How do the physicians make a diagnosis?

878.67 -> Usually, patients present with

880.92 -> symptoms through their primary

882.12 -> care physician or a cardiologist.

884.1 -> We really want to establish

886.44 -> the diagnosis using certain criteria.

889.35 -> Those criterias actually have been developed over

892.425 -> the years ago in

894.72 -> the Framingham Heart Study in Massachusetts, Framingham,

897.18 -> Massachusetts, and those are

899.65 -> very rigorous criteria that we look

901.88 -> for when we examine patients.

904.7 -> We have made criteria and

905.99 -> minor criteria and really they relate to

908.27 -> the shortness of breath so do

909.92 -> the patients get shorter breath at nighttime,

912.865 -> do they need more than a pillow to sleep?

916.46 -> Do they need two or three pillows?

917.81 -> Do they sleep upright?

919.49 -> Do they use a recliner?

920.825 -> Do we see what we'll call jugular

922.85 -> venous distention so the vein in the neck?

924.86 -> When you go to the physician office,

926.61 -> you'll see a lot of physicians looking at the neck veins.

928.91 -> The veins in the neck, the jugular vein,

931.01 -> is connected to the heart so if we

932.81 -> see a abnormality there,

934.91 -> we know that the pressures in the heart are elevated.

937.24 -> The way here, fluid in the lungs, so pulmonary rales.

941.76 -> The way here abnormal heart sound will

944.1 -> be "third heart sound" so normally,

946.52 -> the heart should only have two sounds,

948.395 -> first and second heart sound,

950 -> related to when the valves open and

951.995 -> close and then if you do hear a third heart sound,

954.965 -> that tells us that the pressures in the heart.

957.875 -> The pressures in the left ventricle are elevated,

960.89 -> which will be a sign of heart failure.

962.75 -> Then we have some other criteria, minor criteria,

965.51 -> if the patients have short of breath only on exertion,

967.94 -> so we have this number exertions.

969.9 -> Maybe they're tachycardic so the pulse is very past.

972.825 -> Maybe they have this size of the liver,

975.5 -> maybe they have swelling in their legs,

977.03 -> so those are minor criteria.

979.46 -> Usually, if you have two major or one major

982.13 -> one minor in the right setting,

984.62 -> that pretty much gives you a diagnosis of heart failure.

988.09 -> Now we also know that with heart failure,

991.14 -> a lot of things happen in the body, in the heart,

993.42 -> and a lot of biomarkers are released in circulation.

997.11 -> The heart muscle gets injured.

999.045 -> We have myocyte injury,

1000.68 -> so proteins such as troponin get released,

1003.2 -> and you can measure them in the blood.

1004.94 -> There's inflammation, renal dysfunction,

1007.31 -> neurohumoral activation,

1008.45 -> matrix remodeling, oxidative stress.

1010.625 -> All of those have

1011.825 -> biomarkers or blockers that we can measure.

1014.15 -> Some are more useful than others in all its function.

1017.42 -> For instance, we can measure creatine in the blood.

1020.135 -> As I mentioned, we can measure troponin.

1022.67 -> But one hormone that's really,

1024.83 -> really helpful for us to diagnose heart failure is

1027.83 -> a hormone produced when the heart muscle gets stretched.

1031.295 -> When you have pressures increase in the heart,

1033.98 -> eventually your heart size and

1035.45 -> dimensions starts to dilate.

1037.025 -> Your left ventricle and the left

1038.15 -> atrium starts to dilate,

1039.485 -> and under stress,

1040.76 -> with dilation of the heart muscle starts to produce

1043.73 -> hormones called natriuretic peptides, BNP or NT-proBNP.

1048.305 -> Those hormones are actually very helpful

1050.6 -> because they're telling the kidneys to

1052.685 -> try to eliminate more water and

1054.65 -> more fluid and try to counteract

1056.99 -> the negative hormones that the body is

1059.54 -> producing because there is heart failure.

1062.355 -> They're also trying to lower the blood pressure

1065.005 -> to allow the heart to eject easier,

1068.11 -> to make the ejection easier,

1069.31 -> so they're called vasodilators.

1071.305 -> The vasodilators also help

1074.89 -> the kidneys to eliminate fluid.

1077.565 -> They're also very helpful in diagnosing heart failure.

1081.2 -> A normal person should have

1082.79 -> a very low level of BNP or NT-proBNP,

1085.43 -> maybe a BNP of 30,

1087.08 -> and NT-proBNP below 100

1090.005 -> would be normal for middle-aged adult.

1093.08 -> If those values are higher,

1095.255 -> 2 or 3, 4, 500,

1097.4 -> in the context of

1098.93 -> somebody presenting with shortness of breath,

1100.55 -> for instance, they will help

1102.14 -> to make the diagnosis more perfect.

1104.74 -> Now, how common is heart failure?

1107.705 -> Well, it turns out that it's a disease of the elderly.

1111.65 -> You can see these are data from what they call

1114.02 -> the National Health Assessment and Efficient Survey,

1117.485 -> NHAES, which is

1118.76 -> a epidemiology survey done in the United States.

1121.31 -> We can see that in the younger age group,

1123.89 -> the prevalence, it's very low,

1126.035 -> about one to two percent in patients younger than age 60.

1131.325 -> Slightly higher in men than women.

1133.14 -> Over age 60 or over age 80,

1136.285 -> it's very, very common.

1137.845 -> Essentially, one in 10 people over age 80 or age 60,

1143.47 -> especially men, they have heart failure.

1146.99 -> Over age 80, actually women

1148.97 -> become equally or slightly more likely to

1151.82 -> have heart failure compared to men as

1153.92 -> a result of probably longer-standing hypertension.

1157.25 -> Again, it's a disease of the elderly,

1159.38 -> and if we look at epidemiologic data,

1161.99 -> currently the mean age of diagnosis is

1164.24 -> around 72 and 74 years of age.

1168.155 -> Compared to 20 years ago,

1170.63 -> where we have a lot of patients in

1172.31 -> their 50s as a result of heart attacks,

1174.89 -> now the demographic has changed by about 20 years.

1178.835 -> What about the ejection fraction?

1181.01 -> As I mentioned, you can have

1182.18 -> an ejection fraction measured by the cardiogram,

1184.55 -> which is the amount of blood

1185.63 -> that comes out of the heart,

1186.995 -> and normal ejection fraction

1188.57 -> between 55 and 70 percent means that

1191.54 -> the heart pushes out

1193.1 -> about 55 to 70 percent

1194.93 -> of blood that's inside with every single beat.

1197.51 -> It never completely empty obviously.

1200.62 -> In the past, in the '80s, as I mentioned,

1204.335 -> because of the heart attacks,

1205.73 -> a lot of patients had low ejection fraction.

1208.025 -> You can see the average ejection fraction was in the 35,

1210.41 -> 40 percent range, over time,

1212.84 -> as part of that treatment got better,

1215.93 -> the prevalence increased in

1217.64 -> patients who have preserved ejection fraction,

1219.935 -> which it's especially weak.

1221.735 -> Patients who have high blood pressure by means of

1224.66 -> relation will develop symptoms of

1226.67 -> heart failure because of a stiff heart.

1229.235 -> Their ejection fraction could be normal.

1231.23 -> Again, if you look at the data of people from 2020,

1234.545 -> the mean ejection fraction and

1235.94 -> diagnosis is around 50 percent.

1237.77 -> But we do have about half of the patients have

1241.13 -> a low ejection fraction have

1242.63 -> a preserved ejection fraction,

1244.82 -> when we look at the population data.

1247.235 -> What about the lifetime risk?

1249.575 -> If you're a 40-year-old,

1251.06 -> how likely is for you to develop

1253.37 -> heart failure if you get to age 85?

1256.04 -> It turns out that it is quite likely.

1258.355 -> If you see here data from training and heart survey,

1261.67 -> which now has been replicated in other populations,

1265.54 -> we can see that men and women of age 40

1269.36 -> have one in five risk to develop heart failure by age 85.

1274.415 -> It is quite high,

1277.82 -> and if they don't have

1280.16 -> a myocardial infarction as

1281.93 -> a cause of their heart failure,

1283.01 -> their risk is slightly lower,

1284.21 -> about one in ten for men and

1286.31 -> about one in six or one in seven for women.

1289.61 -> It's still pretty high. Again, it's

1292.01 -> a very unknown factor if you think, especially women.

1296.45 -> If you ask women what is

1298.145 -> their likelihood or the chance

1299.78 -> of developing breast cancer,

1301.49 -> everybody will know that number,

1303.44 -> the chance about one in eight,

1305.525 -> but people don't know that

1307.295 -> there's more likely to develop heart failure,

1309.44 -> for instance, than breast cancer.

1312.695 -> Again, it's an underappreciated disease.

1316.295 -> Patients, once they are diagnosed with heart failure,

1319.22 -> they do have symptoms,

1320.3 -> and a lot of these patients actually come

1322.1 -> to the hospital and get hospitalized.

1324.23 -> About 80 percent of the new diagnoses for

1327.35 -> heart failure may not

1328.79 -> fortunate in the hospital, or again,

1330.635 -> patients presenting to the emergency room with

1332.69 -> shortness of breath or fluid overload,

1334.97 -> or weight gain because of the fluid,

1336.59 -> and they're diagnosed with heart failure,

1338.6 -> and they keep coming back because of

1340.04 -> the recurrent admissions for

1341.24 -> heart failure due to the worsening condition.

1343.535 -> You can see here,

1345.335 -> we made some strides in

1346.85 -> the mid-2010 with a decrease in the number of admissions.

1351.11 -> But recently, those numbers actually had gone up,

1354.305 -> mostly in the urban environment,

1357.485 -> but also some in the rural setting.

1360.665 -> You can see the new cases,

1363.425 -> the adjusted annual new cases,

1365.285 -> it's actually going up.

1368.5 -> In the last decade or so used to go down,

1372.2 -> in the 2004 to 2013,

1375.5 -> and then it started to go up in 2013 until now.

1378.815 -> You have a lot of patients

1379.91 -> hospitalized with heart failure.

1381.65 -> In fact, if we look at the national data,

1385.19 -> there's about 6.5 million

1387.86 -> Americans who have heart failure,

1389.99 -> and we have about 6-700,000 new cases every year.

1395.99 -> About 150,000 patients die

1399.2 -> because of heart failure every year,

1401.03 -> and over one million patients get

1403.64 -> hospitalized with heart failure every year.

1406.01 -> It is a very, very morbid

1408.95 -> disease with a lot of implications for patients,

1412.13 -> symptoms, families, and

1414.47 -> also for society from a cost perspective.

1417.29 -> As you can imagine, most of these patients being in

1421.37 -> the 65 plus age group, Medicare patients.

1425.57 -> It turns out that heart and heart conditions are

1427.88 -> actually number 1 Medicare costs

1430.205 -> every year and there's a lot of work

1432.68 -> now to try to decrease those hospitalizations.

1435.68 -> If you go to the hospital,

1437.57 -> the average length of

1439.37 -> stay it's about five-and-a-half days.

1441.41 -> But if you have more severe heart failure,

1443.66 -> it turns out that you stay longer in the hospital.

1446.48 -> Then, if you have to be put on

1448.22 -> medication called inotrope,

1449.72 -> the cost of care in the hospitalization get even longer.

1452.87 -> If you have to be on inotrope more than a couple of days,

1455.78 -> you're likely going to spend

1456.98 -> two to three weeks in the hospital.

1458.525 -> Again, surplus cost of care from 10 years ago.

1461.39 -> Thirty eight thousand dollars from 2013,

1463.67 -> it's probably 50 plus now.

1465.77 -> So very, very expensive for the society.

1470.285 -> Now, the good news is that we can treat heart failure.

1473.96 -> Once we diagnose it,

1475.055 -> we have a plethora of

1476.33 -> medications and devices to treat heart failure.

1478.97 -> As I mentioned, the main organs

1482.24 -> involved in heart failure are the heart itself,

1484.805 -> then the kidneys, and then the blood vessels.

1487.355 -> We have developed medications that counteract the effects

1491.24 -> of the bad hormones that

1493.1 -> the body is producing on all these organs.

1495.74 -> We have medications such as

1497.27 -> beta blockers or anything that ends in ol,

1499.58 -> carvedilol, atenolol, bisoprolol.

1502.325 -> We have medication called

1504.68 -> angiotensin receptor blocker, neprilysin inhibitor.

1507.889 -> I think the trade name is Entresto

1510.62 -> you may have heard the commercials,

1513.095 -> Sacubitril valsartan is the generic name,

1515.81 -> aldosterone antagonist, such as eplerenone,

1518.81 -> spironolactone,

1520.295 -> SGLT2 inhibitors medications such as empagliflozin.

1525.485 -> That might be the closing to the end enclosing.

1528.665 -> Some people call them progenitors.

1531.05 -> It turns out that those medications

1532.97 -> are actually also affecting

1534.68 -> the kidneys and allowing the kidneys to eliminate fluid,

1539 -> and protecting the kidneys from

1540.92 -> advancing chronic kidney disease.

1543.305 -> They also can affect the blood pressure,

1546.23 -> and they're great in reducing

1547.55 -> blood pressure for patients who have high blood pressure.

1550.295 -> In order to control the fluid accumulation in the body,

1554.66 -> we try to give medications that act on the kidneys,

1557.585 -> and diuretics are obviously

1559.205 -> the mains types of medications water

1561.08 -> fields that will make you eliminate water.

1564.98 -> Medications such as furosemide,

1567.245 -> bumetanide, torsemide may be familiar with.

1570.62 -> They eliminate the salt and water from the body.

1574.16 -> Aldosterone antagonist, as I mentioned

1576.05 -> spironolactone also acts on the kidneys.

1578.36 -> The flozins and ides

1580.46 -> are vehicles b in act on the kidneys.

1582.41 -> Then on the blood vessel again,

1584.03 -> we have the Sacubitril valsartan or

1586.235 -> other medications are pure vasodilators,

1588.95 -> such as isosorbide or hydralazine.

1592.055 -> We use a combination of these medications,

1594.53 -> and we have four main classes of therapy.

1599.54 -> The angiotensin-receptor blockers,

1602.745 -> neprilysin inhibitors,

1604.095 -> aldosterone antagonists and the SGLT2 inhibitors.

1606.81 -> Those four are mainstay of therapy,

1609.735 -> which have been shown in many clinical studies over

1612.705 -> tens or thousand of patients

1614.19 -> to improve the heart function,

1615.96 -> improve the ejection fraction for

1617.58 -> patients who have a low ejection fraction.

1619.53 -> Make it easy to relax for

1621.18 -> patients who have a preserved ejection fraction,

1623.355 -> prevent hospitalizations,

1625.14 -> improve quality of life, and improve survival.

1627.72 -> Again, very good medications

1629.91 -> to delay the progression of heart failure.

1633.865 -> Sometimes unfortunately, the hearttbeat progresses

1636.98 -> no longer patients may develop electrical abnormalities.

1640.615 -> Such as left bundle branch block

1642.735 -> and for those patients who have

1644.355 -> electrical devices such as

1645.93 -> cardiac-resynchronization therapy or CRT.

1649.49 -> In a few slides I'll show those devices.

1653.22 -> Some patients may have the mitral valve,

1656.775 -> which separates the ventricle from the atrium,

1658.95 -> maybe leaking because the leaflets gets

1661.11 -> pulled when the ventricle dilates.

1665.49 -> Those patients may benefit from a MitraClip.

1668.265 -> Again, we have a lot of technologies

1670.695 -> to supplement the medications.

1673.77 -> Now, as I mentioned, one of the advances that

1676.02 -> we've had actually is in the diuretics.

1678.33 -> Diuretics are really the mainstay of therapy.

1680.97 -> For many years, we used to take

1683.4 -> diuretics in form of the oral pills or tablets.

1687.36 -> Now, we have a medication that was just

1690.69 -> approved by the FDA last month as an injectable.

1694.035 -> When patients come to the hospital,

1696.18 -> we have to give the diuretics through intravenous.

1699.255 -> Now this cartridge,

1700.65 -> it's really going to be given

1702.66 -> just as insulin in the subcutaneous form.

1704.985 -> Patients can be at home

1706.86 -> with these type of cartridge for 24 hours,

1709.215 -> 48 hours, you can get a continuous release

1711.615 -> of furosemide instead of coming to the hospital.

1715.155 -> We used to have patients who were taking

1718.56 -> the tablet form of furosemide for many years.

1723.27 -> At some point, the kidneys

1726.21 -> became what we call resistance,

1727.59 -> so they developed what is so-called

1729.54 -> a diuretic resistance.

1731.73 -> Then the drugs wouldn't work,

1733.56 -> so we have to get the patients in the hospital,

1735.75 -> give them intravenous diuretics more in fluids.

1738.505 -> Now we have this option at

1740.39 -> home so instead of coming to the hospital,

1742.4 -> we can do this at home.

1743.825 -> Very exciting news to move and keep patients at home.

1747.785 -> As I mentioned, when the heart starts to dilate,

1751.28 -> you start to have electrical problems.

1753.65 -> That's interesting because the heart is basically a pump,

1756.545 -> it's a mechanical pump that

1758.45 -> is powered by an electrical engine.

1760.73 -> If you're attending some of the

1762.155 -> previous med school classes,

1764.45 -> meaning my classes, you probably

1765.95 -> talked about the electrical system.

1767.645 -> But basically we have a natural pacemaker

1770.179 -> that starts in the right atrium and sends

1772.95 -> electrical impulses through the heart muscle

1775.725 -> towards the left atrium and then towards the ventricles.

1778.485 -> At some point, some of

1780.87 -> these electrical fibers that

1782.31 -> are embedded in the heart muscle,

1783.96 -> become deficient, becomes short-circuit.

1786.225 -> Usually the heart muscle, let's say hypertrophies,

1789.93 -> the ventricle starts to dilate,

1792.21 -> those electrical fibers get

1793.83 -> stretched out and then they could short-circuit.

1796.08 -> Patients can develop an

1798.15 -> electrical conduction abnormalities

1799.8 -> such as left bundle branch block,

1801.51 -> meaning that the impulses from

1803.61 -> the normal pacemaker take

1805.65 -> a very long time to get to the heart muscle and

1809.01 -> as a result the electrical activation

1811.83 -> of the mechanical contraction of the left side of

1814.41 -> the heart occurs many milliseconds

1816.899 -> later compared to the rest

1818.58 -> of the heart to the right side of the heart,

1820.23 -> for instance, on the septum.

1821.655 -> That inefficiency leads to a worsening in

1825.15 -> the heart dysfunction and worsening

1826.95 -> the ejection fraction, worsening ventricular dilatation.

1829.53 -> Fortunately, we have tools to correct that.

1832.995 -> Well, this is an MRI image

1834.54 -> and unfortunate I don't think it's going to play.

1836.88 -> But what it does, it's something called pegged MRI.

1840.315 -> We look at the strain which is how much

1843.51 -> the heart muscle fibers are actually shorter.

1847.71 -> Normally in systolic during contraction,

1850.65 -> the heart muscle fibers shoot shorter.

1852.99 -> In a normal heart,

1854.31 -> which you see on the left side of healthy heart,

1856.755 -> they should shorten and relax at the same time.

1859.605 -> You can see here,

1861.195 -> the color scheme here again,

1863.475 -> unfortunately it doesn't play.

1864.795 -> But you could see that the whole left ventricle here,

1867.63 -> as seen by the MRI has the same color,

1869.685 -> meaning that the lateral wall and the septum,

1871.74 -> the anterior wall, the posterior wall they

1873.515 -> all shorten and relax at the same time.

1875.84 -> In a cardiomyopathy current

1877.55 -> so heart that has the bundle branch block.

1879.965 -> You can see these colors

1881.48 -> become very different in different parts

1883.22 -> of the heart because

1884.45 -> the electrical activation is delayed.

1886.315 -> You can see that, for instance, the septum contracts,

1889.215 -> but the lateral wall is not

1890.7 -> been activated so it doesn't contract.

1892.65 -> We have dyssynchrony in the heart and

1895.79 -> if we have an echocardiographic picture here,

1898.97 -> it leads to ventricular dilatation.

1900.845 -> We have an echo-cardiogram here

1902.615 -> where you see in yellow trace

1904.88 -> the left ventricle in a healthy heart

1906.955 -> and you can appreciate the size is fairly normal.

1909.825 -> If you look at the walls of

1911.67 -> the heart are fairly normal in size.

1914.235 -> Then we look at a heart that

1915.87 -> has the left bundle branch block,

1917.43 -> we see the abnormal EKG.

1919.29 -> If you look at the EKG here compared to

1921.27 -> the normal EKG on this other side,

1923.46 -> you can see this broadening.

1926.535 -> This QRS complex that becomes very large.

1930.825 -> You can see that the heart gets bigger in size.

1934.62 -> Again, after CRP,

1937.92 -> after we correct this left problem out,

1939.735 -> we can see the QRS complex on

1941.58 -> the right side essentially goes back to the normal,

1944.7 -> being narrow compared to before the CRP.

1948 -> The heart becomes smaller again compared to

1950.94 -> the heart prior to the electrical impulse.

1954.99 -> Now, as I mentioned,

1956.595 -> when the heart starts to dilate

1958.2 -> and the pressure starts to increase,

1959.939 -> the mitral valve, which is the valve that separates

1962.16 -> the left ventricle from the left

1963.36 -> atrium, starts to dilate.

1965.175 -> The annulus of the mitral valve starts

1966.93 -> to dilate and mitral valve leaflets,

1968.79 -> instead of closing, they stay open.

1972.225 -> When they stay open, all the blood or

1974.7 -> a significant part of the blood from

1976.5 -> the left ventricle goes to the top of the heart,

1978.87 -> the left atrium and

1980.7 -> all the mitral regurgitation

1983.46 -> is actually the left periods.

1984.765 -> Because just imagine that you have

1986.4 -> a balloon that you start blowing air,

1988.305 -> the balloon gets bigger and bigger and bigger.

1990.27 -> Similarly, the left atrium,

1991.71 -> if you have all these blowback

1993.78 -> or mitral regurgitation over time,

1996.045 -> the left side of the heart,

1997.44 -> the left atrium starts to dilate.

1999.33 -> Now when you dilate, remember we have

2001.4 -> electrical fibers inside the heart muscle fibers.

2004.505 -> When the muscle fibers start to dilate,

2006.665 -> the electrical fiber starts to become

2008.33 -> short-circuit and they produce

2010.22 -> something called atrial fibrillation.

2012.215 -> Oftentimes patients with heart failure will

2014.57 -> present with a atrial fibrillation because of what

2016.76 -> they've put on a patient caused by

2018.62 -> the mitral regurgitation caused

2020.36 -> by the thicker dilatation.

2022.145 -> Medications are very effective

2024.245 -> in remodeling of the heart back to normal,

2028.19 -> but sometimes they are not enough.

2029.975 -> In those cases we have MitraClips.

2032.63 -> We have clips that go inside the heart,

2036.14 -> both from the right side of the heart,

2038.495 -> to the left side then they clip

2040.07 -> the mitral valve and make the leakage less.

2044.33 -> This is an image of one of our patients

2046.16 -> who you can see here,

2047.795 -> this is a transesophageal echocardiogram.

2050.45 -> Echocardiogram is done from

2052.19 -> the stomach so the patients swallow

2053.81 -> the probe and then we

2055.76 -> look from inside the stomach to the heart.

2057.845 -> The stomach and the heart have

2059.165 -> the distinct advantage to be very close.

2062.33 -> We don't have the chest to distort the image.

2065.51 -> We can see the left ventricle here.

2067.49 -> You can see it's a dilated left ventricle,

2069.56 -> and then the left atrium,

2070.955 -> and you can see the mitral valve.

2072.38 -> All of these colors here,

2073.835 -> all these red color means that the blood is

2075.905 -> flowing back into the left atrium where it shouldn't be.

2078.665 -> Then you can see the MitraClip here,

2080.63 -> you can see this very echo dense opec probe.

2086.75 -> Here, it's the clip.

2088.475 -> After the clip you can see there's very little if

2091.385 -> any leakage into the left atrium.

2094.535 -> Again, the MitraClip can

2096.05 -> reduce the mitral regurgitation,

2097.79 -> which contributes to improved symptoms

2099.62 -> in patients and decreases

2100.97 -> the chance of atrial fibrillation or other arrhythmias.

2105.05 -> Now what's interesting, as I mentioned,

2106.97 -> the pressures in the heart will

2108.65 -> elevate when one has heart failure.

2111.605 -> They really gave us the idea,

2113.78 -> can we detect those pressures and

2115.67 -> can we manage those patients?

2117.74 -> Similar to what a endocrinologist

2120.14 -> would advise the patients

2122.18 -> with diabetes because high blood sugar,

2124.43 -> it's a trigger for diabetes.

2126.08 -> We know that if you can measure the blood sugar,

2128.21 -> then you can treat with medications.

2130.67 -> Similar to that, we thought maybe we can build

2132.86 -> a sensor that can actually measure the pressures.

2135.725 -> We have build such a sensor,

2138.89 -> which is a very small in

2140.99 -> size that it's the size of a quarter.

2143.36 -> It's a very simple concept.

2145.01 -> Essentially, it's a capacitor that gets implanted in

2147.44 -> one of the arteries around

2148.7 -> the heart, in pulmonary artery,

2150.53 -> and with the flow around it

2154.22 -> can have this reflections that

2156.32 -> are translated into waveforms,

2158.375 -> and then we can see pressure wave forms in patients.

2162.46 -> In fact, patients at home,

2164.87 -> they have a pillow that they lie on,

2166.595 -> and then they have a button they

2167.87 -> press into the home unit.

2169.58 -> Once they press the button,

2171.35 -> the sensor that's inside

2173.77 -> their pulmonary artery transmits

2176.11 -> the data to a website and the clinicians

2178.69 -> can see the data and they can

2180.07 -> make recommendations in terms of

2182.38 -> medications or diuretics for the patients to use.

2186.335 -> Again, this is one of our patients and you

2187.97 -> can see pressures here systolic,

2189.74 -> mean, diastolic over time for many, many months.

2193.04 -> Again, our nurses and

2194.645 -> patients and some physicians look at those pressures,

2196.76 -> and then they'll call the patient to

2198.53 -> tell them what to do with medications.

2200.48 -> It's all based on this tiny sensor

2203.72 -> that's less than an inch in size inside their hearts.

2207.8 -> What's really interesting is

2209.555 -> a lot of these pressure elevations

2211.76 -> are triggered by what people do, what they eat.

2216.965 -> I just wanted to point out

2218.825 -> to pressure elevations in this particular patient.

2222.095 -> We can see if you look

2225.53 -> before the pressures are coming

2227.27 -> down and they are fairly stable,

2229.61 -> then there's two days here,

2231.71 -> or two time periods where

2234.05 -> the patient had a high pressure.

2236.63 -> If you look at the dates,

2238.16 -> they're actually very telling.

2240.035 -> This is actually Easter and this is Christmas.

2243.335 -> Clearly, dietary indiscretions that led to

2246.26 -> this particular patient having high pressures.

2249.545 -> The two are probably an increasing part intake of salt.

2253.925 -> Our nurses saw that over

2256.04 -> the weekend and the following Monday,

2258.71 -> , they called the patient to tell them to take

2260.3 -> more diuretics because they are these pressures.

2262.73 -> While reacting as I mentioned, just like diabetes,

2265.28 -> if you can monitor the pressures,

2266.855 -> can you treat high pressures?

2268.565 -> One idea that physicians had was maybe if

2271.49 -> we can get the pressures in

2272.75 -> the left side of the heart work,

2274.355 -> pressures elevate to offload

2276.65 -> somehow to the right side of the heart,

2278.75 -> patients will become less short of breath.

2281.24 -> We built something called interatrial shunt.

2285.26 -> Essentially it's a tiny sensor,

2287.87 -> it's a tiny hourglass-shaped device that gets

2291.305 -> implanted into the heart.

2294.86 -> You can see it's very, very small and

2297.26 -> gets implanted through this gap device system.

2300.695 -> It's implanted down there that

2303.53 -> transfers your cardiogram or

2305.27 -> into a cardiac echocardiogram.

2307.01 -> We can see the left side of the heart,

2309.59 -> the right side of the heart,

2310.94 -> and then how this catheter goes through the septum,

2315.785 -> makes the tiny hole in the septum again,

2317.93 -> which is the left side or

2318.965 -> the left atrium into the right atrium here.

2321.305 -> Makes a tiny hole then we give a wiring,

2324.335 -> and then we load this leverage system over

2326.75 -> the wire to place the interatrial shunt.

2330.2 -> Then the shunt it's loaded onto this delivery system,

2335.315 -> the shunt gets placed across

2338.39 -> the septum and then the delivery system

2341.69 -> is retracted and the shunt is pulled back on

2344.93 -> the echocardiography and fluoroscopy.

2348.365 -> The shunt is pulled back.

2351.79 -> There's one opening to the left side of

2354.56 -> the atrium and then one opening to the right side.

2357.425 -> You can see the shunt there

2359.585 -> and we can see the blood then essentially

2362.675 -> flowing from the right and the left

2364.685 -> offloading the left side of the heart and the lungs of

2368.75 -> patients to have less crashes on the left side of

2371.69 -> the heart and hopefully

2374.45 -> having relaxed shortness of breath.

2377.17 -> One of the sides actually,

2379.655 -> in this particular clinical study

2381.38 -> that just finish enrollment.

2383.285 -> Then hopefully next year we'll find

2385.34 -> out if it's truly worth when it's

2387.17 -> compared to control patients

2390.68 -> or patients who did not get the shunt.

2392.345 -> You can see very nicely how the shunt flows and we

2396.155 -> have a flow of blood across the septum of this patient.

2401.375 -> Even a year later, again,

2403.91 -> the shunt stays open and makes

2405.335 -> really nice flow of blood from

2406.88 -> the left side of the heart to the right side.

2408.92 -> We had a few patients in the initial phase

2411.65 -> where all the patients that had the shunt,

2414.245 -> we knew that they got the shunt and they had

2416.48 -> dramatic improvement and now as I mentioned,

2419.09 -> we've just finished the randomized study work,

2421.37 -> about 510 patients across

2423.89 -> the US and Europe were enrolled where one of the centers.

2428.605 -> Then half of the patients got the shunt but

2430.63 -> half of the patients did not get the shunt.

2433.345 -> In a blinded fashion I need a physician

2436.945 -> treating the patient or the patient

2438.64 -> knew if they did get the shunt or not.

2440.925 -> Again, we'll have to wait a year to see

2442.76 -> if the results are positive or not.

2445.22 -> The other thing that can happen, as I mentioned,

2447.38 -> patients have heart attacks

2448.91 -> and then when you have a heart attack,

2450.56 -> you have an expansion of the zone

2452.63 -> especially if you have the F anterior descending,

2455.48 -> governing fewer heart attacks.

2456.92 -> We have a ventricle that can expand and dilate,

2460.505 -> and you have a scarred part of the heart.

2462.98 -> That scarred part of

2464.81 -> the heart is actually deleterious because

2466.88 -> it tears your heart's ability

2468.86 -> to squeeze and shunt normally.

2470.975 -> For a long time, physicians have thought,

2472.88 -> can we remove that part of the heart?

2474.785 -> There's a very famous French surgeon,

2477.47 -> Vincent Dock who invented this procedure,

2480.26 -> the Dock procedure he practices in Monaco.

2483.965 -> Through the surgical procedures,

2486.11 -> you'll be able to cut out this part of

2488.21 -> the heart and reconstruct the heart.

2490.76 -> Great idea but obviously it's

2492.83 -> an open heart surgery

2493.85 -> so I know a lot of people who wanted to do that.

2496.49 -> The physicians came with the idea,

2498.425 -> can we do this in

2499.49 -> a minimally invasive fashion where maybe we can

2503.375 -> have a catheter that goes from outside of

2506.51 -> the chest through a minimal incision,

2510.005 -> and from inside of the heart and

2511.91 -> maybe we can pull these things together,

2513.935 -> and get rid of the scar.

2516.545 -> Indeed, it's a very interesting procedure.

2519.17 -> You have the cardiac surgeons

2520.955 -> approaching the heart through

2522.5 -> the outside through the ribs

2524.075 -> and make this tiny incision and

2526.07 -> then intervention cardiologists going from

2527.975 -> the jugular vein downstream into

2531.2 -> the right ventricle and putting this wire through,

2535.835 -> and then pushing really

2537.26 -> this muscle the scar tissue or being part of

2541.01 -> tissue together and closing

2543.125 -> the heart and only leaving a normal functional part.

2547.46 -> We have seen in the study

2551.345 -> really nice results with patients ejection fraction

2554.18 -> increasing and symptoms improving dramatically.

2557.21 -> Again, this is what

2558.77 -> the heart would look like after the procedure.

2563.47 -> This in clinical trials you we'll see

2565.88 -> it every day as we'll be doing

2567.35 -> the beta [inaudible] FDA while doing these therapies and can say

2571.685 -> if you need a treatment or heart attack patients who

2574.79 -> have this type of problem.

2578.075 -> Other patients, as I mentioned,

2580.07 -> can have part of this function in

2581.69 -> bio patient without cleaning the part of that.

2583.91 -> Well, they do have really big hearts.

2585.89 -> Again, the idea was,

2587.09 -> can we do something to

2588.845 -> constrain the heart and make it smaller?

2591.335 -> Indeed we can have something called

2593.39 -> a cinch device or AccuCinch

2596.15 -> where physicians go from inside the blood vessels,

2601.22 -> through the aorta that go back into the heart and place

2604.97 -> this cinching device on

2606.65 -> the top of the heart below the mitral valve.

2608.84 -> Then they start pulling and making the heart smaller.

2612.245 -> Again, it's a very neat device

2615.35 -> that goes through the only valves,

2616.94 -> again below the mitral valve,

2618.53 -> and gets cinching plates.

2620.51 -> Then over time the heart remodels and becomes smaller.

2623.945 -> As I mentioned, where one of

2626 -> the sites for this study were actually born,

2629.75 -> we deployed the first device

2631.925 -> on the West Coast for this particular trial.

2634.82 -> We're still in the process of

2636.47 -> evaluating at the national level,

2638.78 -> so probably we'll know within the next 40 years.

2641.465 -> In this particular therapy,

2642.8 -> it's helpful for patients with ventricular dilation.

2645.754 -> However, some patients, despite

2648.05 -> our best intentions and

2649.67 -> best medications and devices and surgeries,

2652.37 -> will at some point stop to respond to a therapist.

2657.26 -> They will become what we call

2659.48 -> refractory or advanced or N stage.

2661.955 -> They'll have persistent class core symptoms

2664.37 -> if you remember from the beginning

2665.69 -> of the lecture class

2668.66 -> causing them symptoms with minimal exertion or address.

2672.92 -> Some of these patients can barely

2674.93 -> shower or they can even make the bed.

2677.51 -> They have a really high mortality,

2679.34 -> over 50 percent within a year,

2681.62 -> mostly driven by heart failure.

2684.11 -> That's about 100,000 patients a year, and again,

2686.96 -> there's no more conventional therapy to perform.

2690.725 -> A lot of these patients should be evaluated

2693.11 -> for heart transplantation or heart pumps.

2696.11 -> Heart transplantation it's great,

2700.205 -> you replace the heart with a new heart.

2702.515 -> Unfortunately, we have

2704.15 -> a limited donor pool, and therefore,

2706.67 -> we only do about 3,300

2708.59 -> transplants a year in the United States.

2711.14 -> It's the green bar here,

2713.75 -> which I've obscured by mistake.

2715.94 -> But the number hasn't dramatically increased over

2718.97 -> the last 20 years because we have a limited donor pool,

2723.785 -> and if we did about 3,300 transplants last year,

2727.55 -> we have probably two or three,

2729.74 -> four more people on

2731.48 -> the transplant list waiting for a transplant.

2734.3 -> We had to come up with new ideas on

2737.24 -> how to expand the donor pool and how to

2739.7 -> ensure that the organs that we have

2742.1 -> donated can function for a longer time.

2746.765 -> I'm not sure if you're familiar

2748.28 -> with the heart transplant or

2749.33 -> if you've seen movies about heart transplant,

2751.655 -> the classic where somebody

2754.22 -> gets the heart that puts it on ice and then they

2756.26 -> drive or they fly it to the hospital where the recipient

2760.22 -> waits and then a surgeon places

2761.78 -> the heart into the patient's chest.

2764.915 -> All this transplantation used to be done with the cooler,

2769.28 -> essentially with ice and

2770.93 -> the special solutions of

2772.04 -> the heart when just being on ice.

2773.615 -> Obviously, we realized that it's not great

2777.53 -> and you can't really keep

2779.36 -> a heart from ice more than about four hours,

2781.64 -> maybe five if you want to function

2784.07 -> it normally when you

2786.2 -> place it again into the patient's chest.

2789.11 -> Obviously, that will also limit you to younger donors,

2793.79 -> 23-year-old donors compared to 40, 50-year-old donors.

2797.34 -> Because an older heart even if it's normal will come back

2801.22 -> in a more difficult fashion if it is kept on ice.

2805.815 -> With this, we actually came up

2809.3 -> with a special container called SherpaPak,

2812.96 -> made by this company where the heart

2815.48 -> is placed and it's

2818 -> actually in a very controlled temperature setting.

2821.285 -> We can monitor and the parameters can be

2824.99 -> changed to keep the temperature

2828.44 -> constant but that allows us

2830.33 -> now to extend these actually,

2832.595 -> duration to four or five,

2833.87 -> six hours much safer,

2835.91 -> which allows us to go out to

2839.45 -> maybe 1,500 miles for patients to take donors.

2844.025 -> Allows us to increase the age of donation to 40,

2846.98 -> 50 because the hearts are better preserved,

2849.83 -> so you have a better preservation for

2851.63 -> those patients who are using the SherpaPak.

2854.09 -> But the real game changer,

2855.86 -> I think it's going to

2858.32 -> be something called the TransMedics OCS or

2860.84 -> the heart in a box where we can actually take hearts

2864.23 -> from patients who are traditional donors.

2872.82 -> Traditional donors or patients

2876.46 -> who have so-called bonus of circulatory desk.

2880.54 -> We can place these donor hearts into

2883.48 -> a special system that keeps

2885.43 -> the heart beating as you can see here.

2888.01 -> Here is the heart beating in

2889.63 -> a box and then we can essentially

2892.15 -> transport these and keep it in this box up to 24 hours.

2897.04 -> This is really Sci-Fi, when we look at it,

2901.195 -> it is very real and

2904.135 -> we're one of the few centers in

2905.86 -> the US that's using this technology.

2909.84 -> In September, we did a number of

2913.36 -> patients who have come out of Alaska, Tampa,

2916.45 -> Texas, Minneapolis,

2919.81 -> and things that would not be

2921.4 -> possible before we got this technology.

2923.92 -> I think one of the patients that

2925.54 -> received the transplant, the heart is okay.

2927.67 -> Donor body for about 12 hours,

2930.25 -> which again is something that is just bordering

2933.58 -> science fiction and

2935.14 -> these patients are really well and again,

2937.69 -> allows us to offer more chances to more patients.

2943.015 -> Now, the other thing that has happened,

2945.445 -> we still don't really have a lot of

2948.495 -> hearts even with this type of combination,

2951.465 -> a lot of hearts for all the patients or

2953.61 -> the patients may be too old for transplant,

2956.52 -> maybe 75, 80 years of

2958.02 -> age and they're too old for transplant.

2960.27 -> For those patients we have heart pumps,

2962.49 -> and this is a picture history of a heart pumps.

2966.36 -> These are the first heart pumps that we

2967.86 -> used back in the day,

2969.6 -> in the late '90s.

2971.795 -> This is mid 2000s and this is 2010,

2975.16 -> this is 2020,

2976.495 -> so also becoming small and small easier to use.

2980.26 -> I just put a couple of X-rays for some of my patients.

2983.8 -> This is a patient back in 2007 when I was in Chicago.

2988.165 -> It's a patient from Michigan.

2989.875 -> He was 6'4,

2991.54 -> and 350 pounds and

2993.865 -> really big person and you can see

2995.8 -> the pump it's extremely big.

2997.825 -> Given this is a man,

3000.585 -> clearly someone there was small in size but

3003.12 -> not been able to receive this pump.

3006.165 -> Fast forward a couple of years later,

3008.73 -> another patient that I had met in Chicago,

3012.36 -> which was a 21-year old woman

3014.46 -> who had postpartum cardiomyopathy,

3016.185 -> she developed heart failure after giving

3018.27 -> birth to her second child.

3021.83 -> By then we had this

3024.795 -> harming two sets and so the harming plant,

3027.18 -> we get the harming to the second

3028.77 -> generation pump, clearly much,

3030.87 -> much smaller and then

3033.03 -> very comparable in size to a fibrillation.

3035.43 -> But again, she was about 5'1,

3038.55 -> 120 pounds, so about

3040.98 -> a third in size compared to the gentleman on the left.

3044.04 -> She was able to receive this pump

3046.8 -> and reach out successfully to a heart transplant.

3049.605 -> Then the third generation pumps,

3051.48 -> which are even smaller,

3052.98 -> you can see the heart [inaudible],

3054.78 -> the current pump used that's not being

3058.275 -> able to be implanted completely inside chest.

3062.04 -> So the cycle pumps,

3063.27 -> you can see that implanted in the abdomen,

3066.77 -> and they crossover to backtrack into the heart.

3070.905 -> Newer pumps, they're implanted inside of the chest,

3074.55 -> which obviously makes it much easier and

3077.61 -> allows the surgeon to perform MIMO then surgery,

3081 -> so there's no more [inaudible],

3082.62 -> you don't have to split up

3084.21 -> the sternum and the surgeons

3086.4 -> can make a small incision on the ribs,

3088.92 -> upper, right, and lower left.

3091.2 -> You can see this patient that actually,

3093.03 -> you can see their fibrilator

3095.325 -> in the heart pump, somewhere here.

3097.62 -> You can see the size of the incision for the surgery and

3100.68 -> probably smaller end of the [inaudible].

3103.8 -> Then again see the drive line of

3106.53 -> the patient's heart pump

3108.06 -> coming out and connecting through backwards.

3110.865 -> So really, really exciting technology that we can offer

3114.72 -> patients and they can be very full life.

3118.275 -> This patient got to travel the world,

3121.38 -> Egypt went fishing,

3123.48 -> went to Alaska,

3124.98 -> and so she enjoyed a very good quality of

3127.155 -> life with no obvious hard pumps.

3130.515 -> You can see she's actually made

3133.05 -> the parts where she put her batteries and controllers.

3136.215 -> They don't even know that she has

3137.58 -> one of heart problems so again,

3138.93 -> people have normal quality of life.

3141.87 -> I want to end here and allow sometime for

3144.93 -> questions but things to remember that heart failure,

3147.93 -> it's a complex syndrome

3149.805 -> in older patients usually

3153.225 -> with a very high morbidity and mortality.

3155.4 -> But we do have a plethora of medications and

3158.27 -> devices and surgical options

3160.1 -> available to prove the heart function,

3162.425 -> they improve the quality of life, extent life.

3166.195 -> Obviously for end stage patients who have

3168.135 -> heart transplantation and as I mentioned,

3170.04 -> get new technologies to allow

3171.45 -> patients to receive hearts faster,

3174.33 -> and for those patients who don't qualify,

3176.834 -> we have heart pumps out that still,

3179.61 -> which will increase a patient's again lifespan

3183.75 -> and work through their symptoms.

3185.22 -> We are fortunate to really be at

3187.5 -> the forefront trying to getting care

3189.645 -> for distribution in health center. Thank you.

3194.595 -> Great. Thanks so much Dr. Klein for packing in a lot of

3198.93 -> fascinating important information and

3200.79 -> to about an hour long talks.

3203.355 -> We have several questions and please feel

3205.86 -> free to add others.

3209.69 -> There was a question about differences in

3214.95 -> heart failure risk by environmental settings such as

3220.65 -> the urban versus rural setting and some questions

3224.085 -> about the magnitude of

3227.31 -> that if it's present and what

3228.9 -> the potential explanations might be.

3231.3 -> Yeah, great question. We know

3234.75 -> now that environment can affect the risk factors,

3237.42 -> so everybody environment especially in neighborhoods that

3241.86 -> are exposed to inequality in here and income,

3247.965 -> patients can develop high blood pressure,

3250.32 -> patients can eat unhealthy food,

3253.5 -> they have no way to exercise and

3255.72 -> all those risk factors can lead

3257.355 -> to uncontrolled hypertension,

3259.59 -> coronary artery disease, which are

3261.3 -> risk factors for heart failure.

3263.805 -> In fact, the largest increase in heart rates,

3267.78 -> young African-American men,

3269.97 -> if you compare to other races.

3272.865 -> There's a lot of inequity

3275.79 -> in risk factors distribution of heart failure.

3279.765 -> Is it fair to say though

3281.28 -> that that's been empirically observed

3285.255 -> but the underlying mechanisms

3288.135 -> have yet to be truly elucidated?

3290.865 -> Correct. I mean, I think these are, as you said,

3293.295 -> empirical observations and we think that

3296.25 -> they relate to social factors, economic factors,

3299.19 -> and all environmental factors translate into again,

3305.25 -> the biology which leads to an abnormal heart function.

3309.24 -> There's also a comment

3310.68 -> that it seems that there are so many of

3313.29 -> these new technologies are fairly minimally

3318.03 -> invasive and so there's

3321.54 -> a question about whatever happened to open heart surgery.

3324.6 -> Is there still a role for cutting

3326.82 -> open the chest and doing something that way?

3329.64 -> Absolutely. I think there's still

3331.35 -> a role for open heart surgery.

3332.94 -> Again, a lot of these procedures

3334.29 -> are surgical procedures,

3336 -> it's just that currently surgeons

3337.92 -> can do them in a minimal fashion.

3340.02 -> I mentioned the [inaudible].

3342.57 -> We are one of the few institutions where

3344.22 -> our surgeons do what we call bilateral

3346.65 -> thoracotomy so incisions of

3348.54 -> our cartilages in long

3350.34 -> on the left and right side of the heart.

3351.84 -> If you go to other institutions

3353.76 -> around the CD or in northern California,

3356.25 -> for instance, they still do

3357.27 -> the old traditional open heart surgery.

3359.43 -> I think it's just the techniques and the

3361.89 -> devices allow surgeons to be very creative.

3364.86 -> You still have open heart surgery

3366.96 -> if you need a bypass, for instance.

3369.6 -> Valve replacement is still

3371.79 -> open heart surgery with minimally invasive techniques.

3374.43 -> A lot of the other procedures have become

3376.92 -> interventional procedure so minimal approach

3379.92 -> as I showed the chance,

3382.185 -> of course, into devices and so forth.

3385.155 -> I don't think we'll ever

3387.03 -> completely get rid of cardiac surgery,

3389.22 -> I think there's still going to be an important role,

3391.71 -> but a lot of these procedure are

3393.15 -> becoming more minimal and in fact,

3395.28 -> the cardiac surgeons and interventions

3397.019 -> collaborate and work together during the procedure.

3399.775 -> Another question is the role of physical fitness,

3405.169 -> lifestyle factors, and the relevance of that especially

3409.229 -> as people develop more and stage forms of heart failure.

3413.685 -> It's a great question. I think we

3416.16 -> have pretty good data that physical fitness and

3418.755 -> exercise helps both the heart failure

3421.89 -> with reduced and preserved ejection fraction.

3424.545 -> We have even clinical trials proving there that you

3428.505 -> can improve symptoms and then reduce hospitalizations,

3432.21 -> especially in women compared to men, so very important.

3435.795 -> Obviously, you have to tailor

3438.12 -> the amount of physical exercise that one

3440.28 -> can do and therefore,

3442.26 -> cardiac rehabilitation, cardiac rehab,

3444.21 -> it's a phenomenal resource and we

3446.82 -> encourage all our patients to

3448.41 -> attend cardiac rehab if possible.

3450.42 -> Another question is, well,

3452.1 -> so many effective therapies,

3454.74 -> should we no longer fear heart failure?

3457.755 -> I would say yes,

3459.48 -> that's a great point and we really

3462.51 -> have a lot of therapies so we're

3464.4 -> starting now to talk about healthy recovery.

3466.87 -> We have a lot of those therapies

3468.35 -> where if we can intervene early,

3469.91 -> we can recover the heart muscle,

3472.22 -> bring you closer to normal.

3474.935 -> In 10 years ago, maybe

3476.72 -> heart failure was a death sentence,

3478.16 -> I would say that it's not the case in 2022.

3480.76 -> I wanted to thank again Dr. Klein for

3482.97 -> an outstanding presentation and

3486.105 -> the audience once again for attending,

3487.92 -> and we look forward to seeing you again. Thank you.

3490.86 -> Thank you so much. Have a goodnight.

3492.24 -> [MUSIC]

Source: https://www.youtube.com/watch?v=hSfnw6Dco3A