Listen in as speaker Dr. Marat Fudim gives a post-lecture interview with Dr. Vikram Raje, heart failure and interventional cardiologist at Georgia Heart Institute. Dr. Fudim talks more in depth on heart failure congestion.
Hello, welcome. This is Vikram Raji at the Northeast Georgia um Hospital in the Georgia Heart and Master Symposium. We are here um to talk about um some heart failure topics. I'm an interventional cardiologist, as well as advanced heart failure cardiologist. So, thanks for coming. Thanks for having me. Yeah, no problem. So let's first talk about this idea of congestion. You had a very brilliant thought provoking lecture about blood volume congestion. Can you speak about that? Um You know, the the the idea for this talk came really from the observation that when patients present to the hospital, uh we often find them while we think they are congested. And I always said on the stage, I don't argue with people that patients presenting to hospital congested, but everybody defines congestion different. If we could define it as signs and symptoms of heart failure, you are short of breath, you can't lie flat, your neck means elevated, you might have even have edema or not. But unfortunately, that then does not always translate in a change of for example, weight. So literally, this observation started with residency where if you look back at patients charts in about half, if not more of patients presenting for half a dec compensation, the weight is not different than the baseline weight weeks, months, years ago. So plus minus 2 £3 like we had after our lunch today, we might be two or £3 up, but that's ok, but there was no significant weight gain beyond that in the majority of patients. So that then actually spawned a lot of research into looking what is the discrepancy between weight changes and pressure changes. And there's been a lot of good work done in the last 20 years indicating that patients invariably present with pressure gains preceding hospitalization, but do not have any significant weight gain. So suggesting that not everybody that's congested is necessarily due to volume overload. And then I presented some evidence to demonstrate we actually can measure blood volume people now too. It's a, it's a test that's approved by the FT A called blood volume analysis. And so we've done a lot of studies actually measuring blood volume and measuring congestion as measured with, for example, pressures at the same time and see a lot of discordance. Fantastic. Fantastic. So in summary, you know, we have novel ways of potentially marking how swollen a patient is and how congested they are. So let's talk about about the future of heart failure. What do you think? Where do you think we're going with this field in terms of particular device, therapies, medications before maybe we get to left ventricular cys devices or heart transplant. But so this is a very good point. You know, I think uh the majority of my clinical focus is to expand beyond the advanced heart failure therapies such as Elvan Trans because it really affects a small population of patients. 95% of patients with heart failure to date will never qualify or never need a heart failure therapy such as advanced such as L A or a transplant. Having said that I think the future is super, super, super exciting right now. First of all, we have all these medical therapies that are coming through that are drug based. The reality is that there will be not many more drugs added in the next generation, let's say 5 to 10 years, we just have tapped out. I mean, we have five, maybe six drugs with IV iron, maybe, you know, seventh drug that we can give to people with heart failure, but there will be no more that are any time soon coming to the market. So it's really the next generation of therapies or diagnostics. And I'm making specific one diagnostics. We talked about cards to some degree. Watching the patient with device based diagnostics is just as important as actually treating them because if you don't know what you treat, how you're gonna treat them correctly. So I think I'm a big, big, big, big fan as you are of diagnostics, I do cardio MS testing and other non invasive diagnostics to identify heart failure and prevent heart fails and then for therapeutics. Now there is a whole swarm of device based strategies that are already approved for heart failure such as cardio modulation, bar stimulation therapy. So there are device based therapies that are approved not for the advanced heart failure, but a step before class two, class three heart failure patients. And there will be 10, 20 more coming in the next 5 to 10 years that will be approved for this field. So we need to get ready as a community because there's a lot of other therapies we will have available to our patients. We need to, you know, let them know about it. Great. I think for our audience. Can you touch base slightly on two important therapies with neuromodulation. One is called cardiac contractility modulation and the other therapy is a sympathetic activation with the barrow stem device. Can you comment on both of those? So, ok. So cardio contractility modulation is actually by definition, not on neuromodulation therapy because you stimulate the heart directly, which is actually pretty cool stimulating the heart. It's like a pacemaker inserted in the pacemaker position. You have two leads that go through valve to the interventricular on the right side, you stimulate between two leads and the idea what it does, it actually increases the calcium in the heart. And by doing so, it actually improves the calcium handling of the cell. All right, the concept there is if you improve the calcium centering of the uh calcium handling of the cell, it improves the contractility. So surprise surprise has been developed and tested as a therapy for heart failure with reduced injection fraction between an injection fraction between 25 and 45%. Proved by the FDA. Since 2019, you can go ahead and plant it bear stimulation therapy. Also proved just around the same time in 2019, is an extravascular device. Also pacemaker. We refer to them as PPG pacemaker goes on the skin. But now the lead is tunneled, subcutaneously to the either right or left and allows you to stimulate the parasympathetic nerves, hear the glossy, sorry, the uh ninth and 10th nerve. So those are the parasympathetic fibers that go back to the brain not to the heart directly. And by doing so, uh can then decrease the sympathetic tone increase to the data there. Uh show improvement in quality of life, six minute walk distance and uh reduction and p all clinically relevant markers in patients with ejection fraction of less or equal than 35. So those two device therapies are approved and exactly like you pointed out, you know, present options outside of advanced heart fail therapies. Great, great. Well, in summary, I think we have clearly shown that, you know, heart failure is a moving field. We not only have new therapeutics, but we're getting away from just medical therapy potentially if you're not tolerating medical therapy, if you have a side effect of medical therapy to advanced therapeutics. And doctor said couple few things such as cardiac contractivity modulation as well as the sympathetic parasympathetic interplay with the barrow device. But thank you very much and enjoy the day. Thank you. Thank you for having me.
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