Joey Wahler (Host): It can interfere with daily life, even while resting. So we're discussing advanced heart failure and its treatment options. Our guest is Dr. Gautam Ramani. He's a Cardiologist. He's Medical Director of University of Maryland Medical Center's Pulmonary Hypertension Program and Associate Professor of Medicine at the University of Maryland School of Medicine.

 Welcome to the Live Greater podcast series, information for a healthier you from the University of Maryland Medical System. Thanks for joining us. I'm Joey Wahler. Hi there, Dr. Ramani. Thanks for being with us.

Gautam Ramani, MD: Happy to be here.

Host: Great to have you aboard. So first for the uninitiated, what is, in a nutshell, advanced heart failure and how, of course, would it differ from milder forms of heart failure?

Gautam Ramani, MD: It's a great question. Advanced heart failure is a heart failure that has progressed to the point where symptoms have worsened, and standard pills or electrical devices that we use to manage heart failure are no longer adequate at managing symptoms and maintaining quality of life and preventing heart function from worsening.

Host: So we're talking about a progression here. What are some of the typical causes of that?

Gautam Ramani, MD: Heart failure by its nature is most cases are incurable. So we know that heart failure is progressive. It can occur over, you know, sometimes weeks to months to years to decades, and every patient and every trajectory, may be different. So we know that most cases of heart failure are progressive, and so we monitor patients closely.

 Some factors that can lead to progression of heart failure may be valvular heart disease, arrhythmias, if there are blockages in the heart arteries, or what we call coronary artery disease, or sometimes even despite all of the physician's best efforts and the patient's best efforts, heart failure may just progress on its own.

Host: So that being said, what are some of the common signs and symptoms that indicate a patient already with heart failure may be advancing to a more severe stage?

Gautam Ramani, MD: I think that's really important. So some of the most common signs and symptoms we see are that patients may begin to feel dizzy or have a low blood pressure. And medications that they have been on for, in many cases years, they just can't tolerate them because they feel dizzy or they feel light headed.

 So that's one of the things that we see. Sometimes, despite being compliant and being on the medicines, there is more difficulty breathing. Or there may be more fluid retention just because even if we're in adjusting the diuretic medicines, there may be more fluid retention. Oftentimes we see patients who are admitted to the hospital more frequently.

Sometimes we see that other organs, be their liver or kidney, these organ functions are worsening because the heart may not be delivering enough blood to them. And sometimes our patients who have electrical devices may note that they may be firing as a sign of worsening or there may be increasing heart rhythm problems. So there are several different things that we look at to help determine whether heart failure may be worsening.

Host: Gotcha. So when those meds are no longer as effective in managing heart failure, what are the next steps in treatment options?

Gautam Ramani, MD: Yeah, so the most important thing really is a timely referral. Often times the difference between what's a great candidate for an advanced heart failure treatment and what may not be a great candidate is just time. So as a specialist, what I would say is we always like to see the patients sooner, earlier in the course of their advanced heart failure than later.

 When we see patients earlier, oftentimes we have more therapies that we can offer and the success rate for those therapies may be higher. So really for patients with milder advanced heart failure, we have different devices that may be available, both for monitoring as well as for treatment that may be effective at

restoring quality of life and delaying progression.

Host: So speaking of which, how do say surgical interventions like heart transplants or ventricular assist devices help to treat advanced heart failure?

Gautam Ramani, MD: So for patients that truly have irrecoverable heart failure, meaning that they've been fully evaluated by an expert team and have found that no valve procedure, medical procedure, or other electrical device can safely restore heart function or restore quality of life; we evaluate patients for heart transplant and heart pump.

And I would say heart transplant is the best treatment for irrecoverable advanced heart failure. Where we have more than half the patients live over 10 years with a heart transplant. Truly remarkable survival for patients, who many would not be expected to live a year without it. And heart pumps have progressed tremendously within the past five or six years with the newer pumps and newer monitoring strategies, where we expect almost half the patients with the heart pump to live over five years with very good quality of life.

So we have made tremendous progress both on the transplant side, as well as the heart pump side in patients who are appropriate candidates for either of these therapies.

Host: And speaking of progress, what would be some of the things that are new and different in your world when we talk about treatment of advanced heart failure, whether it be treatment or research?

Gautam Ramani, MD: Thank you for that. So I think I'll focus on the transplant heart pump side and then we can talk about some of the other treatments as well. On the transplant side, there's been tremendous progress in terms of expanding the donor pool. So who can be a donor for transplant in terms of who can be a donor, how the donor heart is maintained and preserved en route. These things expand the geographic access. And so donors that might not have been donor hearts, say 10 years ago, now we can use those hearts to save patients lives. And from a heart pump standpoint, the newer pumps are designed to last longer. These pumps don't break down like they did.

They don't form clots like they did before, and they are just more sturdier and reliable, and we found that patients don't need as many blood thinners on the newer pumps. So they just last longer, they work better, and they are effective at reducing symptoms and improving quality of life.

Now for patients who have advanced heart failure, but we say maybe we want to try devices before we get to a heart pump. There's some really novel things that have been developed, and some of these we offer at the University of Maryland. One is the CardioMEM's implantable hemodynamic monitor. This is a small device that's implanted and sits in the pulmonary artery. It's not powered by a battery and it transmits data so we can measure what patient's fluid levels are.

So for patients who are struggling with fluid retention, who are frequently hospitalized or remain symptomatic, this device has really been effective at reducing hospitalizations and controlling symptoms. There's another device that we can use which is called Barostim. And this is a device which is stimulates different receptors in the chest and has been shown to be helpful at improving symptoms of heart failure.

So again, as part of a heart failure program, when we evaluate patients, we decide what treatment is best for the individual patient because it really is individualized. There's so many treatments out there that we need to figure out what's the right therapy for the right patient.

Host: Must be great to have those options though, yes?

Gautam Ramani, MD: Absolutely. I would say that as a heart failure physician who's been in practice now for 16 years, I have never felt more optimistic about the current state of heart failure care across the entire spectrum. Both the advanced heart failure needing transplant, the relatively early advanced heart failure that we can manage with some of these devices, and even the more moderately symptomatic heart failure where we have new medical therapies that have been shown to be effective.

Host: Switching gears a little bit, Doc, what are some key factors or lifestyle changes that can worsen advanced heart failure and how can patients work to manage or prevent those?

Gautam Ramani, MD: Yeah, lifestyle is critically important, across the spectrum of advanced heart failure, or heart failure in general. So I would say it's important to avoid a sedentary lifestyle. Now we recognize that symptoms may worsen and patients can't walk as far as they did previously, but we say avoid being sedentary, track your steps, walk when you're able to, to the extent that your body allows you to.

That's important. Diet is vitally important across the spectrum of heart failure. We know that when heart failure develops, the body is very sensitive to sodium. You know, sodium can promote fluid retention and can cause a host of other problems. Being properly vaccinated and up to date on immunizations. When you have heart failure, things like influenza and pneumonia, can be much harder on your body.

The body can't recover as much. So being up to date on immunizations and vaccinations is really important. And then just being cognizant of what goes into your body. What other medications are we taking? Some common pain medicines like ibuprofen, or Naproxen can be very harmful in heart failure, so just being aware of what else is going into your body.

Host: And so that being said, Doc, it seems that going back to what you had mentioned earlier about how advanced heart failure by its very nature is progressive. Talk to people if you would please about the importance of following up, being diligent and doing the work quote unquote on their end that's needed in partnership with their medical team, right?

Gautam Ramani, MD: That's really important. I think a diagnosis of heart failure can be a life changing event. It's scary to know that there's something wrong with your heart and it may not be curable. So it can be scary, but I think the important message is that we have treatments. There is a lot as a patient you can do to recover heart function, stabilize heart function, restore quality of life.

So, the most important thing is following up closely with your physician, learning about diet, learning about lifestyle, managing what you can manage in terms of taking your medications, what goes into your body, tracking your weight on a regular basis, and just being aware of your symptoms. You know, how is your blood pressure? Am I getting dizzy? And advocating for yourself. I think as a patient, you know your body more so than anyone and being an advocate, for yourself really goes a long way to ensure that your care is being optimized and if you have those symptoms that we talked about of progressive heart failure, coming to a heart failure specialist so they can evaluate what may be treated and determine the next best treatment plan.

Host: And finally, doctor, you mentioned how scary these conditions can be for people naturally. So because of that, what do you and your team do to kind of relax those fears and put people at ease as much as possible under the circumstances.

Gautam Ramani, MD: Yeah, so we truly use an interdisciplinary approach. We have coordinators who keep in touch with patients to, once we start new medications, inquire, how are those medications going? Are they going properly? For patients who have been admitted to the hospital, and that's how the diagnosis is made, we ensure early follow up with a Heart Failure Bridge Clinic, where again, there is a pharmacist, there is a coordinator to ensure that the medications the patients have access to them, to ensure that the diet is being followed, and that the education, you know, has been appropriate, so patients understand what's going on with heart failure.

And, you know, we really emphasize that in our practice, you know, we don't treat numbers or statistics that we really individualize the care to the patient, and the family that's there. And, you know, we really emphasize how that the treatments we have now really can be life changing and that have really altered the trajectory.

 So we try to use an interdisciplinary approach, where we're honest and realistic, but we also hope to empower the patient that their condition, there's a lot that's within their control and their physician's control.

Host: I'm sure that's comforting for people watching and listening to here. Folks, we trust you're now more familiar with advanced heart failure. Dr. Gautam Ramani, a pleasure. You're doing great life saving work. Thanks so much again.

Gautam Ramani, MD: Happy to be here. Thank you so much.

Joey Wahler (Host): And you can find more shows just like this one at umms.org/podcast, as well as on their YouTube channel as well. Now, if you found this podcast helpful, please do share it on your social media. I'm Joey Wahler, and thanks again for being a part of Live Greater, a health and wellness podcast brought to you by the University of Maryland Medical System.

We look forward to you joining us again.