Transcription:
About Advanced Heart and Lung Care

Prakash Chandran (Host): Welcome back to Heart Speak with Baylor Scott and White Heart and Vascular Hospital in Dallas and in Fort Worth, joint ownership with physicians. Baylor Scott and White All Saints Medical Center Fort Worth provides a Heart and Lung Disease Center to the residents of Fort Worth, Tarrant County and surrounding areas.

Dr. Salman Gohar is the Medical Director for Advanced Heart Failure and Mechanical Circulatory Support Service for the center and on the medical staff of Baylor Scott and White Heart and Vascular Hospital Fort Worth. He's an advanced heart failure and transplant cardiology specialist. And he's going to be joining us today to discuss the Advanced Heart and Lung Disease Center and left ventricular assist device transplants.

My name is Prakash Chandran. And Dr. Gohar, it's really great to have you here today. You know, I wanted to start by asking what is the Advanced Heart and Lung Disease Center at Baylor Scott and White All Saints Medical Center, Fort Worth?

Salman Gohar, MD, FACC (Guest): Well, thank you Prakash for having me. The Advanced Heart and Lung Center at Baylor All Saints and Baylor Scott and White Medical Center primarily is designed to treat two conditions. One within the heart and one within the lungs and because as the heart receives insult it develops what in medical term we call cardiomyopathy, patients start living with what is called heart failure.

And heart failure is a serious life-threatening condition if left unchecked and this problem, the heart cannot pump as well as it should either because the heart is unable to contract or relax as well as a normal heart does which results in then symptoms. This occurs primarily because the blood and back up into the lungs and a pressure buildup within the tissues of the body, which results in swelling, primarily in the lower extremities and sometimes even the abdomen and when the body doesn't receive oxygen rich blood, it doesn't perform normally. And you have symptoms such as weakness, fatigue, shortness of breath on minimal exertion or when in extreme forms, at rest.

So because heart failure can affect both heart and lungs, or sometimes the distinguish, the true area is not clear, or the true demarcation is not clear; we have the Advanced Heart and Lung Center here to help to figure out where the problem is arising from. Our team at the Advanced Heart and Lung Center looks at causes of heart failure and works with the lung doctors to help guide the patient's treatment plan.

While there may not be a complete cure for heart failure due to damaged heart muscle, there are still many treatments that can effectively improve symptoms and an experienced team of doctors here at the Baylor All Saints Medical Center and the Heart and Lung Disease Center are able to work together to pinpoint the most appropriate treatment for each patient.

Host: Yeah, it sounds amazing. And like you have a multidisciplinary team there. Tell me what types of patients are referred to the Advanced Heart and Lung Disease Center.

Dr. Gohar: That's a great question. The Advanced Heart and Lung Disease Center is geared towards providing comprehensive, personalized care to primarily complex patients, but we treat any or all varieties anywhere from mild functional patients, mildly symptomatic functional patients, to really complex clinical scenarios, such as complex congenital heart disease, inoperable coronary artery disease, dilated cardiomyopathy, hypertrophic, or restrictive cardiomyopathy, infiltrative cardiomyopathies or inoperable valvular heart disease which often result in refractory life-threatening scenarios. So, we offer several treatment options using a highly personalized approach to treatment, which oftentimes is based on an individual's age, medical history, type and stage of heart failure and personal preferences.

Treatments could range from simple heart failure medications to synchronization of the heart, as well as controlling risk factors, placing devices to prevent sudden cardiac deaths, such as implantable cardio defibrillators, promote pulmonary artery sensors, such as CardioMEMS devices. And when the patients cross a certain threshold, which is defined as stage D or end-stage heart failure; we assess them for either a cardiac transplant or a left ventricular assist device.

Host: Yeah, I was just going to ask you about that because I know that the heart and lung disease center was the first in Tarrant county to be certified to perform left ventricular assist device transplants, or LVAD for short. So maybe you can talk to us a little bit about what is LVAD and what does the certification mean to residents of Tarrant County?

Dr. Gohar: Well, this year in 2021, CM centers for Medicare and Medicaid sent their surveyors to Baylor Scott and White All Saints. And we were successfully certified to perform left ventricular assist device implants. Now this is an important, this is an important milestone because you cannot be certified unless you have all the key pieces of a multidisciplinary team that has been specifically trained to implant and then manage these patients in the long run.

This certification certainly represents a huge leap forward for heart failure care, especially advanced heart failure treatments here in Tarrant County and the surrounding counties as well. This certification allows us to deliver higher level of cardiovascular care to a population of patients that are being seen here in Fort worth.

And it also represents an option for us to improve the quality, as well as longevity of the lives of our patients. So, you have to go through a lot of steps to get to an LVAD. It is certainly a therapy that is reserved for a select group of patients. But what we do is we put the patients through a set of testings. And they see a number of specialists including me as the medical director here. They also see LVAD certified surgeon, Dr. Dan Meyer, our surgical director. And we also have Dr. Andres Leal who is also certified LVAD surgeon working with Dr. Meyer. Both of them see the patient. We have a social worker, a palliative care specialist, as well as our own dedicated LVAD coordinator, Taylor Teagarden, who is just an absolute star of our program to help understand what are the criteria that the patient qualifies for and meets to be eligible for an LVAD. There are a number of policies and guidelines that are present to support this. And we have an number of care team members, not only within the core group, but the whole hospital that are there to support these patients if they're here for other procedures. That is what the program entails.

Now what is an LVAD? That's a great question. A left ventricular assist device is primarily a pump that is connected sort of in parallel to the heart. And what it does is it helps support partially or sometimes completely, the function of the left ventricle, which is the main pumping chamber that generates blood pressure. Oftentimes when you develop heart failure and your ventricle or your heart becomes dilated, your heart's unable to generate that forward flow. Which then results in all the heart failure symptoms I mentioned earlier. With a left ventricular assist device, the heart's able to continue to pump in the background, but a lot of the flow and a lot of the work load is picked up by the pump.

This pump bypasses the aortic valve which connects the heart to the body and then directly pumps this blood into the aorta, which is the main blood vessel going to the rest of the body. So thereby you end up having an additional support device that can provide up to 10 liters per minute of flow to a body that's actually really begging for more flow, more perfusion and patients feel better. The quality of life improves, symptoms improve, congestion, such as shortness of breath, tissue swelling, all of that remarkably improves as well, especially after the first three months are over.

Host: Yeah, that is quite amazing. And I guess I want to ask a more basic question. I've obviously heard of a pacemaker before. How is LVAD different from a pacemaker?

Salman Gohar, MD, FACC (Guest): That's a great question. So, completely different devices in many regards. A pacemaker is an implant, is an implantable device that has leads that are inserted into the heart. That the device itself, the pacemaker itself is about the size of a quarter or maybe larger, maybe smaller than a hockey puck, but that is just implanted by a specially trained cardiologist called an electrophysiologist most of the times, who then sets the leads in the heart, and adjusts the voltages so that the pacemaker depending on the reason why it's placed does its function by either electrically stimulating the heart, or just sitting in the background, watching the heart for any disturbing or fatal rhythms, in which case it can jump in and shock the heart back into rhythm.

And left ventricular assist device is implanted by a specially trained surgeon with the help of specially trained cardiologist who screens for the appropriate patients. Once those patients are identified and meet criteria, then the surgeon takes this patient to the operating room and they actually sometimes have to open the chest, doing a sternotomy and exposing the heart and putting the patient on bypass, a cardiopulmonary bypass, and then they core the apex of the heart.

And sew a special ring into which the LVAD is plugged in. The LVAD is truly the size of a hockey puck if you put it in your hand and it has an inflow cannula that pulls blood from within the heart's cavity and then pumps it at a 90 degree angle out. So it's a centrifugal device, especially the HeartMate 3, which is the recent iteration of this device.

And this blood is directed through a conduit that has been sewn into the ascending aorta. As you can understand, it is a big procedure. So, you, you also have to do an additional step, which is you have to pull a drive line, which is basically nothing more than the power supply of the pump through the anterior wall of the abdomen. And it externalizes either on the right or left side of the abdomen. And it's connected to a controller that monitors the LVAD and also connects it to batteries that the patient will then use to become free and walk around. So, it's a complex procedure. There are different ways of doing it.

There's some minimally invasive approaches as well, but by its inherent nature, this is a large surgery and it is designed to serve two purposes and these have changed as well based on the most recent Medicare guidelines and updates. It was previously designed to either bridge a patient to a heart transplant that was sick and did not meet criteria for a heart transplant or the implanted lifelong reason which was previously termed as destination therapy. Now these terms are moving out or of being phased out because the devices are so good that they almost never malfunction. So now the therapy's either short-term, which is also more of a bridge to transplant or on a long-term basis, which is destination therapy or previously known as the destination therapy. You just have to prove that the heart is sick. You actually have to measure the flows in the heart, and they're supposed to be less than 2.2 liters per minute, per meter square. This is the cardiac index that we use. The ejection fraction should be less than 25 and there must be evidence that the heart and the patient has what is termed functional class four symptoms, meaning that they're so sick because of the heart failure, they can barely get up and walk to the bathroom at times. That's how bad it can be.

Host: Yeah, absolutely. I was just going to ask you about the criteria to get the LVAD, but you know, you covered some of that there. My question is obviously things are pretty severe before the procedure. And even though it is a fairly big procedure, talk a little bit about the outcomes after the LVAD.

Dr. Gohar: We always weigh risks versus benefit in every case, every procedure, every surgery that we do, is it truly indicated. And that's why all the workup is done before we ever consider implanting an LVAD. But the key clinical trial, the Momentum 3 clinical trial, which is now about three years old in terms of its publication of its results; has given us significant data to understand how patients do with this type, or this generation of pump. Now I'm talking about HeartMate 3. This is pump that has a centrifugal flow design. It's not the old coaxial flow design meaning the blood enters at one angle and then leaves at about 90 degrees.

That's what a centrifugal flow pattern is. And on top of this pump has six magnets that are magnetically, levitating, the rotor in a magnetic field and a computer chip that revs up the speed of the rotor spinning within this magnetic field by a certain amount, every 1.8 to two seconds. And what it does is this design feature has allowed the pump to prevent blood clotting. Blood is tissue, and we have to understand that we're flowing tissue, not water through these mechanical devices. So by understanding how the body reacts with artificial material, such as titanium and the energy and friction that's produced by rotating a rotor this fast, all that has been mitigated.

And as a result, this pump has a pump clotting rate of 1%, and that has resulted in a significant decrease in pump replacement surgery. So once the pump goes in, you're able to live without needing a major surgery, unless something catastrophic happens. So, what happens is after the first three months, patients experience a significant increase in their energy level.

Their renal function improves, their kidneys and their liver gets decongested. The appetite should start coming back. They should start feeling better and start engaging in life and getting to know this additional piece of their body, which is really essentially another limb that they have now to live with, but they should be able to get back and start being able to walk, go out play golf, play music, take their grandchildren and children out to dinner for walks, being able to volunteer in a hospital and give back to the community and have some return of self-worth and confidence that is so critical in someone's mental health being that they're able to do all of that without getting short of breath, they have the energy, the stamina to participate in life and be there with their loved ones during holidays and and all the important times in one's lives. They also are able to drive. Many times they're able to return to jobs that entail computer work. So there's a lot of improvement in both functional status, quality of life, and then longevity certainly is close to a heart transplant at two years. It's not quite there. The two year survival is about 79% for a left ventricular assist device. And for a heart transplant is about 80 to 83%. So it's really close. Not quite there yet.

Host: Yeah, that's truly fascinating, Dr. Gohar and it really sounds like this LVAD procedure is such a technological advancement and boon to heart failure patients really just supporting better outcomes for the future. So, it's been fascinating to learn about it. Just before we close here today, is there anything else that you wanted to share with our audience today?

Dr. Gohar: I would just say that this is a very perfect time for Fort Worth as a city. We are building very complex but at the same time well-oiled team that well oiled machinery that that helps manage really complex problems. Patients coming in oftentimes really on death's door. Being able to put them on extra corporeal membrane oxygenation device, such as a VA ECMO, supporting their organs, getting them out of cardiogenic shock and then back on their feet and be able to walk out of the hospital. And then have a longterm option, such an LVAD or a transplant assessment right here in Fort Worth. This is a huge deal, in my opinion. This has never happened. And this is a huge leap forward for cardiovascular care in both Fort Worth and Tarrant County.

Host: Yeah, there's absolutely no doubt about it. And Dr. Gohar, we really appreciate your time today. So thank you so much.

Dr. Gohar: You're welcome. Thank you for having me.

Host: That's Dr. Salman Gohar, Medical Director Advanced Heart Failure and Mechanical Circulatory Support Service for the Heart and Lung Disease Center at Baylor Scott and White All Saints Medical Center, Fort Worth. And he's also on the medical staff at Baylor Scott and White Heart and Vascular Hospital Fort Worth. Thanks to you for checking out this episode of Heart Speak, you can find a specialist on the medical staff at Baylor Scott and White Heart and Vascular hospital in Fort Worth or Dallas by calling 844-279-3627. Or visit bswhealth.com/heartdfw. If you found this podcast to be helpful, please share it on your social channels and be sure to check out the entire podcast library for topics of interest to you. Thanks again for listening. My name is Prakash Chandran, and we'll talk next time.

Announcer: Baylor Scott and White Heart and Vascular Hospital, Dallas and Fort Worth joint ownership with physicians.