Joey Wahler (Host): Of the more than 6 million Americans living with heart failure, about 10 percent have advanced heart failure. When conventional heart therapies and symptom management strategies are no longer working, you may need more advanced options. The VCU Health Hume Lee Transplant Center in Richmond has the right team to give you the personalized, expert care you need.

Our guest, Dr. Keyur Shah. He's a Transplant Cardiologist and Chief of Advanced Heart Failure at VCU Health. This is Healthy with VCU Health. Thanks for listening. I'm Joey Wahler. Hi there, Dr. Shah, thanks for joining us.

Keyur Shah, MD: Thank you. Thank you for having me on.

Host: Great to have you aboard. So first, in a nutshell, tell us a little bit about your medical background and what it is that you do at VCU Health.

Keyur Shah, MD: I'm a Cardiologist. I'm a physician that focuses on caring for the heart and I have sub-specialized to care for patients with heart failure or cardiomyopathies. Cardiomyopathies is just a fancy word for heart muscle disease. A lot of my clinical focus and time is spent with people who have advancing or advanced heart failure, that is not responding to typical therapies, such as medications, pacemakers.

Host: So what exactly do we mean by advanced heart failure?

Keyur Shah, MD: Advanced heart failure is when the symptoms of having a weak heart cannot be managed with guideline directed medical therapy. And these are pills that physicians and cardiologists use to protect the heart that has become weakened because of one of many causes. Once the patient becomes progressively symptomatic, they may, despite medications, continue to have fatigue, shortness of breath, frequent hospitalizations, worsening kidney or liver function, unexplained weight and muscle loss, arrhythmias, and even in extreme stages, confusion, and episodes of lightheadedness and passing out. Frequently, they become intolerant of their meds because of low blood pressure, and they have very poor quality of lives.

Host: Wow, so that's quite a gamut of possible issues that can arise. So who exactly is most at risk of advanced heart failure?

Keyur Shah, MD: So, there are certain risk factors that increase the chance that you'll develop heart failure or weakening of the heart. For example, most common identified causes of heart failure in the United States include high blood pressure or coronary artery disease, which is blockages in your heart arteries that can cause heart attacks. Those are two causes. But nowadays, we've become familiar with many other environmental or genetic causes. For example, there are a large group of cardiomyopathies that result from genetic mutations that are passed on from family members. No fault of the patient. Also, exposures to toxins, such as certain medications for treatment of cancer, or excessive alcohol use, or narcotics and drugs such as cocaine and methamphetamines, are all potential stressors and methods that the heart can become injured and weakened, and patients can develop heart failure.

So the initial treatment for patients who have weakening of their hearts are common medications that are used to preserve heart function and improve symptoms. And it's when these medications lose their effect over time, where the heart becomes progressively weaker, that we call it advanced heart failure.

Host: Gotcha. Before we move on to the next item here, I just want to pick up on something you mentioned about this sometimes being a genetic issue. Obviously, there are other things in the medical world that people can get screened for to see if they're more susceptible because of genetics. Does that apply in this case with the heart?

Keyur Shah, MD: So, genetic heart diseases are becoming increasingly identified as a cause of cardiomyopathy. In cardiology, we don't recommend routine genetic screening for all patients. However, if you have a family history of cardiomyopathy or heart failure in one or multiple first or second-degree family members, it's very reasonable to discuss genetic testing with your provider or cardiologist.

Now, there are also other patients who have a certain shape or certain type of cardiomyopathy that should definitely get genetic testing if they're interested. It's important that before anyone considers genetic testing that they discuss this with their provider to understand potential implications and, if positive, what surveillance and screening will look like afterwards.

Also, potential implications on other family members who are now put into an at-risk category if they're descendants or siblings of those with genetic or hereditary heart disease.

Host: Okay, so to backtrack on something else for a moment, you mentioned a list of the numerous symptoms one with advanced heart failure can experience. If someone does, what should they do?

Keyur Shah, MD: If you experience any of the symptoms of a weakened heart, and just to review them, they fall into two categories. When the heart doesn't pump blood efficiently to your body; you can have fatigue, poor appetite, lightheadedness, breathlessness, or if there's congestion or backup of blood flow, you can have fluid accumulation, swelling, difficulty breathing, difficulty lying flat.

If you start developing these symptoms, you need to speak with your physician and specifically explain the symptomatology of going on. If you feel that you are having an increase in breathlessness and it is new, it is also appropriate to call 9-1-1 or go to the emergency room for evaluation. Because the cause of this, even though we're talking about heart failure here, needs to be differentiated from other items such as lung disease, pneumonias, blood clots, anemia, or a long list of other things that can cause someone to feel tired, fatigued, short of breath.

Host: Understood. So the first step is then determining that whatever is going on is happening because of the heart. Now, one option for advanced heart failure treatment is something called a left ventricular assist device, also known as LVAD, that's implanted into your chest. So, Doctor, what patients are typically candidates for that and how does that work?

Keyur Shah, MD: A left ventricular assist device, or as we call it in the field, an LVAD, is a mechanical pump that goes in to assist circulation in the heart. It's placed in the heart, and it pumps blood into the aorta. So it creates a parallel circulation of blood flow to help a weakened heart increase circulation to vital organs.

The result of implanting an LVAD includes improvement in the signs and symptoms of heart failure, including fatigue, exercise tolerance, reducing congestion, and reversing things such as muscle wasting and shortness of breath. When considering an LVAD, one must be sure they've exhausted all other therapeutic options because it's an extraordinary surgery but also life changing, and we reserve this for patients who are not responding to medical therapy and have a poor quality of life.

Host: Life changing in what way?

Keyur Shah, MD: This treatment, which has really only been introduced and contemporized in the last 15 years, offers options to patients who may not be candidates for transplant and may otherwise die from their heart failure in the coming year. So many patients, hundreds of thousands around the world, have derived benefit from this and ended up gaining improved quality of life and adding years or decades to their life.

Host: So, my understanding, Doctor, is that if LVAD isn't an option, that a second one would then be a heart transplant and I think just about anyone listening understands how major an occurrence that would be. So who are the best candidates for that?

Keyur Shah, MD: Well, I think this is an interesting topic. And I would perhaps reframe it. I would suggest that for a patient with advanced heart failure, there are three options. One is heart transplantation. And heart transplantation is an extraordinary intervention for patients. However, the evaluation process is stringent and there can be medical or surgical limitations for those who might be candidates.

A heart transplant can give a patient a decade or more of additional life. And they would have to be on immunosuppression and close monitoring with a transplant program. Just like an LVAD, it improves quality of life, it improves the patient's functional capacity, and our goal is to return to as much normalcy as possible. A heart transplantation is an extraordinary intervention, is available at limited centers, such as VCU, and we would advocate for it in appropriate candidates. But the truth is many patients are not candidates for heart transplantation for various reasons. Maybe they're too old. Maybe they have antibodies that will cause rejection. Maybe they just choose not to have one. For those that are not candidates for heart transplant, or are too sick to wait and achieve a heart transplant on the waiting list, we clearly advocate for consideration for a left ventricular assist device. Now, there is also a third option if the patient is not a candidate or chooses not to have either of these two interventions.

Some patients may choose to live out the rest of their life with palliative therapies, such as living with a drip at home or even enrolling in hospice when the time is right. So we try to tailor treatment to our patients' goals. Some may be spending time at home. Others may have goals of living as long as possible to see their children graduate or spend time with their grandkids.

Once we define their goals, we guide them to their therapeutic options based on their medical, surgical candidacy. It's a collaborative decision making process where the patient is a key player in the center of the therapy we decide to offer or the patient chooses.

Host: Understood. And so good that you mentioned that third option and then just to close out discussing transplant. If a patient appears at first, initially, to be a candidate for it, what are the basic steps involved in that journey, so to speak, before the operation can take place, because there are a number of them, right?

Keyur Shah, MD: Absolutely. Heart transplantation patients and recipients, have a remarkable, unique journey to get to where they are. They undergo a multidisciplinary evaluation process to ensure that biologically they can accept an organ, surgically it can be accomplished, and psychologically they're ready. Then, when deemed appropriate and ready, are placed on the waiting list. Based on their blood type, their body size and height, and then also the urgency determined by how sick they are; they may wait a short or long period of time before an organ is available. In other words, there's an uncertainty to how long you'll wait. It's not something that can be scheduled. Once a heart transplant is complete, patients live on immunosuppressive drugs, which are managed closely by the transplant center to achieve certain levels to prevent rejection.

They're monitored closely for rejection and infection. The first year includes frequent testing and monitoring, including periodic biopsies of the heart. And slowly after that, the monitoring becomes less intense. Patients return to normalcy in terms of function and rehabilitation and recovering from their heart failure somewhere between three and nine months after the surgery.

The survival with heart transplant has become extraordinarily good. Someone who undergoes a heart transplant is expected to live with that heart for an average of 13 years. Some patients may live in excess of 20 years. Others, if they have complications, have shorter lifespans. The average survival at one year is about 94 percent at VCU.

Host: And I'm going to ask you about the care offered at VCU in just a moment, but just to finish up about transplants, Doc, as someone involved in the heart transplant world, is it safe to say that a heart transplant remains even today, and I know it's been around for a number of years now, but is it safe to say it's still one of the remarkable medical procedures known to man? Because it sure seems like it is.

Keyur Shah, MD: Absolutely. It is a unique and extraordinary journey for the patients and the providers and an extraordinary gift from the donors. One of the challenges, as you mentioned, is some of the aura of uniqueness is related to the rarity in which it takes place. Unlike other routine procedures and surgeries in medicine, there's only 4,000 or 5,000 heart transplants taking place annually every year.

And at each individual center, the number of heart transplants they do can range from as low as 10 to as much as 100 at some of the larger cities. But overall, it's a rare occurrence and only for very select patients, back to the LVAD, which is a device that you can pull off the shelf and offer someone who may not be a candidate for heart transplantation or may not live long enough to wait for a heart transplantation.

Host: In summary here, these are clearly life changing and often life saving procedures, so what would you tell our listeners in closing, Doctor? Why someone should come to VCU Health for advanced heart failure treatment?

Keyur Shah, MD: First of all, thank you for this opportunity to share our program with listeners. I think at VCU Health, patients with advanced heart failure will receive a comprehensive evaluation. And our providers will collaborate with your doctors and surgeons to come up with a treatment plan tailored to the individual. I think also we're a wonderful place for second opinions because we routinely take on higher risk patients.

For example, ones that might require a multi organ transplant, such as heart kidney, heart liver. We'll think outside the box, and we have access to some of the most contemporary procedures, devices, knowledgeable physicians who are on the avant garde of research and technological development. Certainly, we'll do our best to ensure that you are having a comprehensive and enjoyable experience.

Host: Well said. Well folks, we trust you're now more familiar with Advanced Heart Failure Treatments. Dr. Shah, a pleasure. Thanks so much again.

Keyur Shah, MD: Thank you.

Host: And for more information about VCU Health's Advanced Heart Care Program, you can call 804-828-4571. Again, 804-828-4571 or please visit vcuhealth.org/transplant.

If you found this podcast helpful, please share it on your social media. I am Joey Wahler and thanks again for listening to Healthy with VCU Health.