May 27, 2024 • 46 mins
Dive deep into the heart of cardiology with our esteemed guest, Jennifer Beckman, MSN, ARNP, CHFN as she shares her transformative journey from a nursing assistant to a key player at the University of Washington Heart Institute. Her passion for patient care and clinical excellence is palpable as she talks about the advances in mechanical circulatory support that she's witnessed and contributed to. She is committed to maintaining a delicate balance between her administrative responsibilities and her direct work with patients, where the heartbeat of her mission lies.
The landscape of LVAD programs and heart allocation systems has rapidly evolved, and Jennifer offers a front-row seat to understanding the complexities of this shift. With the 2018 UNOS policy revision, we explore the nuances of qualifying for LVAD and how this affects patient treatment decisions. Bleeding risks, comorbidities, and the ethics of patient care—it's all under the microscope. Jennifer's insights reveal the critical importance of a tailored, patient-centered approach in the ever-advancing field of cardiology.
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Episode Transcript
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Speaker 1 (00:01):
This is Coffee and Cardiology.
Speaker 2 (00:05):
In this podcast, we sit down with a faculty from the
University of WashingtonDivision of Cardiology to
discuss the very latest indiagnostics therapeutics and, as
a special bonus, we ask whatmakes our cardiologists tick.
We are so very pleased to haveJennifer Beckman join us today.
(00:28):
We have actually been trying toget her on Coffee and
Cardiology for a bit of time andI'm really glad that the
schedule has actually worked outto invite you in here, jennifer
.
You have some interesting andunique roles here at the
University of Washington, butbefore we get into those, tell
(00:49):
us about your journey to thisplace that you're at right now.
Speaker 3 (00:55):
Yeah, thank you.
Well, thanks for inviting me tobe on the podcast.
I feel honored.
It's my first podcast ever, sohere we go.
Speaker 2 (01:03):
We're honored actually.
Speaker 3 (01:15):
So I started my medical journey about 17, 18
years ago.
I decided I want to become anurse and was in nursing school
and became a nursing assistant,and the only job that was
available in the hospital Iwanted to work in this was in
Wisconsin was on the cardiology,cardiothoracic floor, and so
that was where I first took careof patients that just had
surgery or were at heart failure, had heart attacks, those types
(01:38):
of things, and immediately fellin love with the population.
After I graduated from nursingschool, I was a bedside nurse
for a few years and then wasrecruited to be their VAD and
heart transplant nursecoordinator, and so that really
took me much further into thespecialty which I am still
(01:59):
working in today, which is great.
And I further fell in love withthe population, which is great.
And I further fell in love withthe population.
I got a very broad sense of howto take care of patients at the
end stage of their heart failurejourney, and the program that I
worked in was very small, andso I fulfilled not only the
clinical duties but I alsohelped really grow a program and
(02:21):
understood things from aprogrammatic hospital building
standpoint, which is it's a lot.
There's a lot to entail allthose details.
So then I decided why not goback and become a nurse
practitioner while I was busydoing that and went to school,
(02:41):
became a nurse practitioner andwas recruited out here 10 years
ago this July which is timeflies when you're having fun and
I joined University ofWashington 10 years ago and
worked clinically this wholetime and then started really
working on my leadership skills.
The last five, six years havedealt into quality in our
(03:07):
program and then last fall tookover as the associate director
of our program for mechanicalcirculatory support.
And just having a blast, havinga blast, I love it.
Speaker 2 (03:19):
That is fabulous, and it strikes me that the roles
that you have played even, itsounds like, from really early
on in your career, haveincorporated not just the
clinical work but also asignificant administrative role
in this, what is now aburgeoning and, dare we say, a
(03:40):
fairly well-established field.
But when you first got intothis it probably was very much
in the building phase.
Speaker 3 (03:47):
Yeah, absolutely.
When I was a staff nurse, ourLVADs, our left ventricular
assist devices, those were stilldevices that didn't last very
long.
It was the XVE pumps which ifyou got a year to a year and a
half on support, you were luckyand only for bridge to
(04:13):
transplant for those patients.
And you know, I saw HeartMate 2come out, I saw HeartMate 3
come out, the HVAD pump, and soour technology has grown so much
in the last 10, 15 years andit's been just wonderful to be a
part of it and to be a part ofreally changing a program along
with the changing technology hasbeen really special to be a
(04:34):
part of, and so some of theother work.
I've done some research as wellwith our clinical engineering
team and it's just fascinatingwhat we can do from that type of
research to say, okay, how canwe better manage these patients
with our current pumps and whatideally would be a next
generation pump that would workbest for our patients?
Speaker 2 (04:58):
Yeah, you've sort of grown in your career along with
this really rapidly changingthing.
But I would guess it takes abit of a special person, maybe
even somebody who's flexible, tobe able to kind of morph your
career and your focus along withthis really rapidly changing
technology.
Speaker 3 (05:17):
Yeah, I don't know if my husband would say I'm a
flexible person by nature, butthank you for that, jim.
No, I think I have a veryorganized mindset, and
especially so in my work life,and so you know the type A
personality, self-driven type ofmotivation.
(05:38):
That's definitely how I woulddescribe myself, and I think
when you're jugglingadministrative and clinical
duties in a super sickpopulation, you have to be ultra
organized, and so, thankfully,I found a path for myself that
highlights those attributes,which helps being successful.
Speaker 2 (05:57):
Well, tell us a little bit more about kind of
your administrative roles ingeneral and maybe even some of
your clinical roles, because youare an administrator for a lot
of people who are on the frontlines as well as doing frontline
work yourself.
What is it like to actuallysort of supervise people who are
caring for patients onmechanical circulatory support
and care for these patients?
Speaker 3 (06:19):
Yeah, well, I think to take a step back.
When I was approached to domore administrative work, you
know, in the past few years itwas very important to me to
maintain my clinical competenceand I think you know there's a
lot of leaders in healthcare whothey have to leave behind their
(06:40):
clinical work just because ofthe work they do and it's
full-time work and it was veryimportant to me to not lose that
, first and foremost because Ilove taking care of patients.
It's what gets me up in themorning, it's what got me into
this job in the first place,this career, and I still find
huge value in talking topatients and taking care of them
and making them feel better,and so for me that was very
(07:04):
important and I'm very happy andlucky and blessed to be able to
do that with a leadershipadministrative role here.
So I think working with peoplewho are also taking care of
patients when I have myadministrative hat on is helpful
because I can see areas ofimprovement very quickly,
because I'm boots on the groundwith them, so I can see where
(07:26):
maybe there's gaps.
That I had a blind spot in froma programmatic standpoint, that
I didn't know it was there, andso it's helped me be able to
move things forward.
I'm hoping in a positive way forthe program because I am seeing
what's going on on a day-to-daybasis and from an
administrative standpoint.
There's many things that I'vebeen doing, but I think the
(07:49):
biggest thing is I help manageand maintain our Joint
Commission certification for ourprogram, and so CMS.
You have to have acertification body for a program
like a Mechanical CirculatorySupport or LVAD program, and so
there's many, many things youhave to prove to the Joint
Commission on a yearly basis,and then there's an every
(08:12):
two-year on-site visit that youhave to host and prove that you
are doing things and havingcompliance and following their
standards and your own hospitalstandards.
And so I had my first on-sitevisit that I really helped
manage this past January and itwent very well and I was very
relieved to have it over withand understand the process a lot
(08:35):
more.
So that's a huge part of myadministrative role with the
program.
Speaker 2 (08:40):
Absolutely.
It strikes me that it reallydoes take a village to take care
of a VAD patient, that this isnot something that is done by
one person, but the VADcoordinators are really kind of
the ones who are boots on theground, who are front and center
(09:01):
, with whom nothing else isactually going to happen.
But maybe you could talk aboutthat structure, because it's a
little bit different, I think,than other parts of healthcare
that our listeners might be usedto.
Speaker 3 (09:12):
Yeah, yeah, absolutely we.
You know LVADs are so special,even 15 years after you know,
more than 15 years after theywere created, that we really
need to have a team of expertsnursing experts that are there
for the patients 24-7 ifsomething should happen.
And that's what our bagcoordinator team is.
(09:33):
They are wonderful, excellenthuman beings.
I couldn't have a better teamhelping take care of this
population.
We have four full-time bagcoordinators here and they
really help and support patientsstem to stern.
Once an implant goes in, theyare there, they're in the OR and
they're with them in the ORwhen the VAD gets turned off, if
(09:54):
they have a transplant andthey're on the phone with
hospice end of life, they'rereally there, stem to stern, in
hospital, out of hospital.
And I think it's very importantbecause there are things
medically that could be going onwith a patient with an LVAD
that could be related to theLVAD or they could be completely
(10:14):
unrelated, but because theyhave an LVAD, we really need to
have a clearinghouse of makingsure patients are being taken
care of appropriately.
They're on blood thinners, sowe need to make sure that if an
intervention needs to happen,that we don't stop blood
thinners, so they're really thesafety net for the patient and
they get to know them extremelywell.
They know their spouses andcaregivers, animals, dogs, what
(10:37):
have you.
They know them so, so well.
And again, this is part of whatbrings me joy in this
population is you really developrelationships with our patients
and their families, and the VAGcoordinators even much more so,
because they're their firstphone call if something's going
wrong.
They talk to them in the middleof the night, on the weekend,
during holidays, christmas time,whatever, should there be a
(10:58):
problem, and so we couldn't dothis work without them, and they
are just wonderful.
Speaker 2 (11:05):
I have to say that that is absolutely true.
So I still get some of theemails from the mechanical
circulatory support program andwhen a patient passes away, the
level of detail that is shared,you know, confidentially in that
email and this is aconfidential group, it's not
like this, you know, goes out toeveryone.
But the personal description ofthat email and this is a
(11:26):
confidential group, it's notlike this goes out to everyone.
But the personal description ofthat patient, the personality
of the patient, that comesthrough.
It's beautiful to read thatactually, and I don't know that
many other VAD programs andmaybe that happens everywhere,
but my impression is perhaps alot because of you.
But my impression is perhaps alot because of you.
This is the character of thisprogram.
(11:46):
It is not just one that'stechnically excellent, it is one
that actually sees the patientsfor who they are.
They're not a machine.
Certainly you may have amachine in them, but they are a
person and I think you guys do agreat job of holding that up.
Speaker 3 (12:01):
Thank you, thank you so much.
Yeah, I, I personally I alwayscare for patients like they're
my loved one dad, mom, grandma,grandpa, whatever, sister,
sibling, and I hope that's youknow.
It's patients first,patient-centered care, and
that's what it should be.
And so I think, especially withend-stage heart failure, we can
(12:22):
do so much for patients withall the devices and I mean you
know this, jim, with yourethical hat on there's so much
that we can do.
It's really hard for our teamto just, especially at end of
life, for patients to step awayand say, okay, enough is enough.
We know it's time.
And so having someone thatpatients can recognize, either
(12:44):
in the hospital or on the phonefor their family or the patient,
is so special and it justbrings that patient's journey to
an end in such a beautiful,respectful way.
I hope we never lose that inour program With you leading.
Speaker 2 (12:58):
I don't think let's wind the clock back a little bit
on the patient experience too,because one of the fascinating
things that I find is sitting inand I haven't done this for a
while, I need to go back to thisbut sitting in on the selection
committees.
There's such a fascinatinginterplay.
As you are sitting there tryingto figure out who should
(13:22):
receive these devices, what arethe issues that play into it,
maybe you could tell us a littlebit.
Bring the curtain back a littlebit.
Tell us about what goes on inthose I guess you could call
them selection committeemeetings?
But, it's a little bitdifferent than that, even.
Speaker 3 (13:35):
Yeah.
So those meetings are where wetake any advanced heart failure
patient who needs advancedtherapies and we bring them to a
group of our specialtyclinicians so there's probably
50, 60 people that participatein these and we really look at
patients, stem to stern and saywhat advanced therapy options
would fit that patient best andwhat would serve them best in
(13:59):
the future.
And so in this day and age,with how the world of transplant
is and MCS, it's changed a lotin the last five years or so and
it's been really interesting tosee that dynamic change.
But I think the most importantthing is really looking both not
(14:20):
only medically butpsychosocially which patient may
best fit which therapy.
And so because of the specialtyfolks that we have in the room,
we're really able to look atthat from the ground up and make
sure we're making a greatdecision for the patient.
So I don't know how much backof the curtain work.
(14:43):
I can tell you, but thediscussions can be very lively
and sometimes it takes multiplemeetings to come together as a
team to decide yeah, this is thebest option for this patient.
Our VAD coordinators ifsomeone's going to potentially
have a VAD, they are involved.
They do education with everysingle potential patient to make
(15:04):
sure patients are making thebest decision, that they have
all of the necessary informationto make a decision, which is
very important because I thinkwhen you're talking about LVAD,
it's scary and people Googlethings and they shouldn't, and
they see things on the internetand they might not have all of
the information to make a gooddecision for themselves either,
(15:25):
and so we definitely have ourteam involved right away.
Even if you know we think, yeah, they're probably going to go
for a transplant, we get theminvolved right away.
Speaker 1 (15:34):
You talked a little bit about those changes.
So, pulling back that curtain alittle bit, what are some of
those big changes you've seen inkind of how you guys make
selection?
Speaker 3 (15:46):
Yeah, well, in 2018, the UNOS heart allocation system
changed and really that changedthe face of LVAD programs,
because having an LVAD was youweren't getting as priority for
transplant listing, and so youwere able to transplant patients
who have short-term MCS devicesinstead of durable MCS devices
(16:06):
much faster, and so ournationally this is published
data the LVAD implant numbersare quite low after that change,
and so the face of how to treatpeople is just a little bit
differently.
There are certainly those folksthat need a different therapy
before a transplant, and that'swhy we have LVAD therapy for
(16:28):
sure, or age is a preclusivedecider with them.
Speaker 1 (16:35):
So, yeah, and when your voice is in all of that
conversation, I mean obviouslythere's maybe advocates for
different therapies but how do?
You feel like that?
Speaker 3 (16:47):
voice is heard in that process.
Sometimes patients.
It's very clear we should begoing to transplant In those
patients where either transplantor LVAD could be an option.
That's where we start talkingabout more nuances, like how is
(17:09):
the ease of the patient gettingback to the hospital, because
with an LVAD you need to comeback to the hospital very
frequently.
Do they have great socialsupport?
Is there a caregiver lined up?
Is there a backup caregiverpotentially lined up?
Because these patientstypically need support for a
little while.
It's very similar to transplantbut a little bit different.
So we just try to weigh eachaspect of patients and then
(17:32):
medically, there's reasons whypatients aren't great LVAD
candidates as well.
So for an LVAD, you need alarge left ventricle for the
LVAD to fit appropriately andyou need a right side of the
heart that works well.
So if those aren't the case,then LVAD therapy isn't a great
option either.
Speaker 2 (17:52):
What are some of the other considerations in LVAD
candidacy?
Speaker 3 (17:57):
Yeah.
So a big enough ventricle isneeded.
A right side that workssomewhat well is needed Not
perfectly, but somewhat well.
They need to have socialsupport.
I think medically that's reallythe big two things that you
need to have a patient be wellsupported on an LVAD.
And then really it's justlooking at comorbidities,
(18:18):
because usually patients whenthey get to us they've been
through everything mitral clips,a lot of heart failure meds, a
lot of hospitalizations.
They probably have pulmonaryhypertension, which isn't a
problem for our population.
And then really the right-sidedfunction is a huge problem
because if it's not working well, then the LVAD you're going to
have a lot of problems managingthat patient longitudinally and
(18:41):
then just making sure that theycan come back to the hospital
for readmissions if they need it, and then a lot of clinic
visits and testing.
Speaker 2 (18:49):
How about kidney disease?
Speaker 3 (18:50):
Yeah, kidney disease, thank you.
So end-stage kidney disease isa problem, so having a patient
who requires dialysis on LVADtherapy is a very big challenge
for us.
There's a lot of dialysiscenters in the area that are
nervous about taking someone onan LVAD because their blood
pressure isn't like a normalperson's and they require more
(19:14):
training, and so if someone's ondialysis, that's typically
quite a barrier for us currently.
Speaker 2 (19:21):
Yeah, and that's really too bad because a lot of
them actually are either neardialysis or actually on, and
that would be.
That's a population that can bevery stabilized, because that's
a problem for transplant too,right.
Speaker 3 (19:34):
Yep, unless we can do a heart kidney transplant.
But yeah, that's absolutely,and we have taken patients.
Sometimes it's hard to know iftheir renal disease and
dysfunction is related to theirheart failure, and so if you fix
the heart failure, you maysupport their kidneys a little
bit better.
And so we've taken somepatients who've had pretty
decent kidney dysfunction andlargely they've done okay.
(19:57):
Some needed dialysis in theshort term and then were able to
get them off prior to discharge, but yeah, that can definitely
be a barrier as well.
Speaker 2 (20:05):
How about bleeding issues.
Speaker 3 (20:08):
So all patients on LVAD therapy need
anticoagulation with warfarin.
There was actually a recenttrial that was published last
year called the ARIES trial, andthe ARIES trial looked at if we
really need aspirin or not forour patient population with the
HeartMate 3 LVAD, and the ARIEStrial looked at if we really
need aspirin or not for ourpatient population with the
HeartMate 3 LVAD, and the trialshowed that technically you
don't, based on their end pointsof the trial, and so
(20:31):
programmatically we made adecision that any new HeartMate
3 LVAD patient was not going tobe started on aspirin and
they're just on warfarin, whichis a huge change for the fields
worldwide, big change and so.
But there are problems.
So if patients aren't able totolerate anticoagulation with
(20:51):
warfarin prior to, or if theyhave significant bleeding events
, we definitely need to look atthat prior to an LVAD implant
because they certainly willprobably have bleeding events
after the fact.
Same with.
You know, if patients haveongoing cancer history, anything
that would enhance theirbleeding or clotting risk, we
need to look at and we usuallytalk to our hematology oncology
(21:15):
partners about those patients tosee if we think we can safely
support them.
Speaker 2 (21:20):
But it sounds like having cancer is not a
contraindication necessarily.
Speaker 3 (21:23):
Not necessarily.
Yeah, surprisingly, we havepatients right now who have
active cancer right now withtheir LVAD.
I think it depends on what kindand how aggressive it is, and
that's why we always haveoncology involved to help us
decide.
Are we going to be benefitingthe patient by supporting their
heart if they have an ongoingcancer, if their life risk is,
(21:47):
you know, if it would make senseto move forward with that?
Speaker 2 (21:51):
Yeah, how about psychiatric disease?
Speaker 3 (21:54):
Yes, a lot of psychiatric disease.
Like I said before, when we putan LVAD in a patient, we really
own that whole person, and thatincludes psychological diseases
and supporting them from apsychosocial standpoint
afterwards.
So, yeah, we have patients whohave addiction medicine concerns
(22:18):
, who are actively usingsubstances that go on to therapy
, that we need to support.
We are very fortunate we havean addiction medicine program
and team here at UW that helpssupport our patients and sees
them after their implant, andthen we also have a psychiatrist
(22:39):
as well now, which is wonderfulfor our patients.
We also have a support groupfor LVADs LVAD patients and
their caregivers and we'relooking at trying to expand that
in different ways to supportthe patient versus their
caregiver a little bit.
One of the things we know isthat caregiver burnout and
stress is very high.
(23:00):
It's actually higher thanpatient stress level because
that caregiver feels this huge,immense responsibility to keep
their loved one alive, and so wereally want to focus in the
future that's one of our points.
Moving forward as a program isto help support the caregivers a
little bit more.
Speaker 2 (23:19):
Why is it so stressful for caregivers?
Besides, this whole issue ofsomebody's life is dependent on
a pump.
What does the caregiver?
Actually have to, which is badenough, I totally get that, but
what is the?
Yeah?
What sort of stresses docaregivers?
Speaker 3 (23:36):
experience, I think you know the education that
patients and caregivers get isvery robust, and I think they
just worry they're going to dothe wrong thing in general.
So you have the electricalcomponents, which is scary
enough, and then you have all ofthe medication and all of the
different timing, and it's a lot, and there's a lot of changes
(23:58):
up front, and then patients areusually debilitated, so they
have a physical need ofrehabilitation when they get out
of the hospital.
And then we have the littlething known as the driveline,
which is the electrical cableexiting the abdomen which
connects the computer or thecontroller of the device to the
rest of the pump, and so thatexit site.
(24:20):
We stress very seriously thatif it gets infected it could be
a very serious event for thepatient.
And so I think we stress all ofthese things and the patient's
still in a recovery phase andit's falling on the caregiver to
really be on it with all ofthese things.
(24:40):
And really when they get homethey have to come and see us at
least once a week for the firstmonth and then every other week
for a few months and thenmonthly thereafter, and so it's
a lot for someone to manage, andthat's if it's just the two of
them, if they have children athome or if there is other
dependents.
It's a lot to put on someone.
Speaker 2 (25:00):
So they have to drive the patient too, right?
Correct Can patients drive withan LVAD.
Speaker 3 (25:05):
They can drive after about three months.
We just want the sternotomy toheal, but after that we do allow
.
As long as they're stable andthey haven't had any dizziness
or symptoms where we think therewould be an issue with driving,
we do allow them to drive afterthree months.
Speaker 2 (25:21):
Wow.
Speaker 3 (25:22):
Yeah, that's neat though.
Speaker 2 (25:24):
Well, I mean a lot of patients with LVADs do return
to some semblance of normal life, right?
Speaker 3 (25:30):
That's the goal, that's really the goal of the
therapy and that's what we tellpeople.
It does take a while for theirheart failure symptoms to get
better after VAD, especially ifthey've been dealing with heart
failure for many, many years.
I usually quote people at leastsix months when they get out of
the hospital to where they startturning a corner and feeling
better.
And I always just remind themthat they've been in heart
(25:53):
failure for so, so long thattheir body needs time to really
recover once they have goodblood flow through the rest of
their body.
And so we have patients who aretypically they come in and they
are frustrated because they sayI have good blood flow through
the rest of their body.
And so we have patients who aretypically they come in and they
are frustrated because they sayI have good blood flow, I
should be feeling better andmore energetic.
And they just forget thatthey've been through a major
operation and have a lot ofrecovery phase and we send
(26:17):
people to cardiac rehab.
Everyone goes to cardiac rehabto get functionally a little bit
more rehabbed quicker.
But yeah, it can take quite awhile for that recovery phase to
happen.
Yeah, I can imagine, andprobably everybody's a little
bit different in that too, butour goal is that they're able to
(26:37):
do things that they lovedbefore, aside from getting into
water or doing rugby.
Speaker 2 (26:42):
No more competitive swimming with an LV.
Speaker 3 (26:45):
No swimming, no hot tubbing, no bathing in the
bathtub.
But yeah, other than that, likeif patients want to travel, we
really try to make it availableto them.
There are high risk things thatwe don't want them to do, like
boating in case they would fallover in the boat, or motorcycle
riding really mitigating risk ifat all possible.
(27:08):
But they've had a new lease onlife.
A lot of the times thesepatients would not be alive
within a year, typically if theyhaven't gotten the therapy, and
so we and me personally, Iencourage them to do things that
bring them joy, plan thingsthat bring them joy.
You know, I usually ask in myclinic visits what are you
(27:29):
planning?
Speaker 2 (27:30):
That's something you're going to enjoy.
Speaker 3 (27:32):
Are you going on vacation, you're going to see
the grandkids?
You know what are you going todo.
That'll bring you, bring youhappiness.
Speaker 1 (27:40):
How do you balance that conversation when there may
be just still being evaluatedthat like there is all this
optimism and you know you couldhave this many years and you
could be doing these thingsafter your surgery versus I mean
complications or not getting atransplant or whatever it is
like?
How do you balance that?
Speaker 3 (27:59):
conversation?
John Michael, that's anexcellent question.
It's really tough because ifsurgery and recovery goes well
and patients take care ofthemselves, typically they do
really well, but complicationshappen all the time.
We haven't talked about stroke.
Stroke is the biggest, mostscary thing patients ask me
(28:23):
about and ask our team about isa debilitating stroke, and they
do happen.
They're rare but they happen.
So you can have all theoptimism in the world but we do
tell people that they are atrisk for readmissions, a stroke,
bleeding issues, right, heartfailure.
(28:44):
We do have to have thatconversation, yeah, and it's
tough when you have thosepatients who you think are going
to sail through and do reallywell and then it doesn't happen
and they're in the hospital alot or they're just not feeling
well or they get an infection.
It's tough, it's really tough.
It's tough for us as the teamtaking care of them, but we're
(29:08):
not in their shoes.
And so there's been some work,some qualitative work, looking
at if patients could do thisagain, would they?
And we actually asked thatquestion in our.
We do a quality of lifeassessment for our patients and
it's really interesting whatpeople say.
There are patients where Iwould look at them objectively
(29:30):
and say oh, this is someone inthe hospital a lot, or they've
had this serious complicationand I would think maybe they
would choose not to do this andthey do.
And you talk to them about itand they say well, I've had two
Christmases with my family.
Of course I would exchange allof this hardship to get more
time with them.
And then you have otherpatients who maybe are doing
(29:51):
seemingly well and they said Iprobably wouldn't have done this
again in hindsight.
So it's really tough thoseconversations, and you never
know what someone's willing tobasically put up with to get
more time in this life.
And it's not for us to judgeand it's not for us to try to
quantify for them.
It's for us to give informationand for patients to make their
(30:14):
own decision and then for us tosupport them as much as possible
after the fact.
Speaker 2 (30:19):
That is such a key point to make.
It's so hard to predict whatpeople are going to consider
worthwhile.
There's an entire literature ondecision regrets about these
different things, and I haven'tlooked into it for a while, but
it strikes me it's probablyquite similar to what you're
describing is that we can'tpredict what people will say
that they regret or that they'regrateful for.
(30:40):
And likewise there was manyyears ago a study, a randomized,
controlled trial, of PAcatheters.
Of course, in order to get intoit you didn't need one, and so
it was highly skewed in peoplethat you know didn't need them,
but it didn't show any mortalitybenefit.
The quality of life was better,ironically, in the PA catheter
group, which kind of made nosense.
But one of the things he did asa sub-study was actually say
(31:03):
how much time would you tradefor perfect health, and it
varied so dramatically betweenwhen you asked them implant,
when they were in the hospitalin throes of heart failure, and
then after they made it out ofthe hospital later on.
Later on they were willing totrade a lot less time for
perfect health because they werefeeling better, but at the
moment when they're feelingquite poorly, they were willing
(31:27):
to trade more time, but thatshift over time, over months and
months, was really dramatic.
It's very hard to predict howpeople are going to respond to
these things?
Speaker 3 (31:34):
Yeah, absolutely.
And there are folks too.
I see this in a lot of theyounger population but they get
really tired of carrying theperipheral equipment around too.
And so the body imageespecially.
I mean not only the youngerpopulation, I think I see it
more, I hear it more in theyounger patients.
I think after a while they seekgetting rid of that because
(31:58):
they miss going swimming, theymiss just getting up and going.
They don't want to be attachedto things anymore, and that's a
whole different psychologicalmind shift is when you're
dependent on five pounds, fiveand a half pounds of equipment
that you have to always beattached to.
You know you have to sleep withit and shower with it and you
just can't disconnect from that.
(32:20):
And so it is interesting howthings change over time.
And those young patients I seea lot of the times they feel
better faster and they want tojust move on from the therapy
faster.
Sometimes they can if they're atransplant candidate, sometimes
they can't if they aren't.
Speaker 2 (32:36):
Well, that's a great segue.
I wanted to ask you about thedifference in patient psychology
between bridge to transplant orBTT bridge to recovery, which
is rare, bridge to decision,which is even more rare at this
point because we have peripheralmechanical stroke to report
ones support devices anddestination therapy or DT.
Speaker 3 (32:56):
Mm-hmm, that's a great question.
So I think there's twodifferent ways that I see
patients looking at this, andone was just brought to light.
I think when folks are focusedon getting transplanted, there's
(33:17):
always a carrot to what they'redoing.
They always say, okay, I'mdoing this because I want to get
transplanted, or I'm doing thisbecause I want to hurry up and
get listed.
I want to hurry up and getlisted and there's a focus there
specifically towards transplant, and I think that's great.
(33:41):
And transplant is still thegold standard for advanced heart
failure therapy, although thesurvival curves of both LVAD and
transplant are almost verysimilar now, which is fantastic.
But I worry about thosepatients not really enjoying the
time they have and I remindthem that this time that they're
waiting to be listed or gettinga transplant is actually
they're doing amazing work.
(34:02):
They're getting their bodies ina healthier place.
They're going to go intotransplant in a healthier state
and hopefully recover a lotfaster and have better outcomes
from that.
And there is need for that timeperiod on an LVAD if they're
waiting to get transplanted.
But I see a lot of motivationto get listed to get
transplanted and sometimes haveto remind patients that it's not
(34:25):
a free lunch when you gettransplanted.
You're trading a disease for adisease because it's not a fix
to what's going on.
There's a lot that involvespost-transplant as well and
there's complications that canhappen post-transplant as well.
And then you have thedestination therapy group and in
that patient population I wasreminded by a patient recently
(34:47):
who our committee decided youknow what, this patient is not
going to be a transplantcandidate, that's going to be
off the table.
And the patient told me he wasrelieved relieved to have that
limbo taken off of his plate.
And I was like huh, I guess Inever really thought about that
waiting period.
(35:08):
You know, I think once patientsare listed and they have an
LVAD, they're always waiting forthat phone call.
They're always stressing aboutwhen is it going to happen?
They ask me all the time whendo you think it's going to
happen?
And it's like I don't know whenit's going to happen.
But to have someone say youknow what it was, it's actually
a relief to know that this isjust what my life is going to be
like and now I can kind offocus on doing things I enjoy.
(35:30):
It was really interesting to meto kind of hear that
perspective.
But I think for us, for clinicalmanagement, you know, we really
in our program we treat peoplethe same if they're listed or
they're destination therapy.
And I think it's very importantthere's a lot of crossover in
our patient population.
So if they're not a transplantcandidate today, they may become
(35:51):
a transplant candidate if theylose weight or stop using
substances.
But if they relapse orsomething else happens, they may
be destination therapy.
And so we have kind of a yinand yang to this all the time.
But the only thing I will sayis that someone is for sure
destination therapy.
We may not see them as often asthe other folks and so we give
(36:14):
them a little bit longer leash,just a little bit.
But they can call us and youknow we tell them when to call
us if there's problems all thetime.
Speaker 2 (36:22):
That is so fascinating.
There's such an interestingdynamic, especially in when
people are going back and forth,potentially going back and
forth and how your staff you andyour staff have to kind of
manage that.
You're managing expectations,you're personal counselors to a
lot of these patients.
It sounds like you aredispensing wisdom on a regular
(36:47):
basis to help people actuallycope with their lives and thrive
in the situation that they'rein.
But having to hold all of thattogether, it really strikes me
it takes a special individual, aspecial set of individuals, a
special team to be able toprovide this holistic care for
people.
Speaker 3 (37:04):
Mm-hmm.
Yeah, it's truly.
It's not just a cardiologyproblem.
It's, like I said, stem tostern.
It is definitely a holistic wayof providing care and I'm
thankful that we have teammembers now to help us with some
of these things.
It would always be great tohave more support for patients,
and that's why we look at addingmore support groups and things
(37:26):
like that, because even witheverything we offer, patients
still want more.
Some of them still want aVAD-specific substance use group
support group, for instance,was asked of me in the last
couple months or just moreage-specific support groups, so
the younger people can talk tothe younger people about what
(37:48):
they're dealing with versuspatients who are in their 70s
and 80s.
They have a different need base, right.
And so, yeah, it really it's aspecial subspecialty.
Again, that's I love it, that'swhy I'm still doing it all
these years later.
Speaker 1 (38:06):
Well and you are dealing like in this very
interesting place close topotential death and dealing with
that a lot, and you talked alittle bit about supporting
caregivers is a big goal.
How do you support yourself andthe team in thinking of
supporting through all of thatemotional and mental challenges?
Speaker 3 (38:26):
Yeah, yeah, our teams we really celebrate the highs
in our patients and the highsare really high.
You know, getting someonesuccessfully transplanted that
I've known for five years justhappened last week.
It just it's amazing,absolutely amazing.
You know the family.
(38:46):
They hug you in the ICU.
You're so excited when thingsgo well and then you have
patients, alternatively, who youtake care of for eight years,
who die because there's either acomplication or there's a
comorbidity that is bringingthem to the end of their life.
And I think as a team we talkabout it.
We kind of debrief.
(39:07):
If we need to, like Jim wasmentioning, we send out emails
notifying the rest, the broaderteam, when someone passes away.
And that's kind of ourrespectful way of saying goodbye
to that patient because we knowthem so well.
But it's tough, it's reallytough.
Sometimes you just need to sitdown and talk it out and say,
(39:28):
hey, this was really tough.
How are we going to moveforward?
Is there something we can learnfrom this for another patient?
And really, again, end stageheart failure is what we're
dealing with, and so bringingsomeone to that respectful death
is a gift we can give people.
And I think we forget about thata lot, and it's this weird
(39:49):
juxtaposition of we'resupporting someone with a means
that we didn't have available tous 30 years ago, 25 years ago,
even almost 20 years ago.
It's just wild that we can dowhat we do and get people more
time, but knowing, yeah, it isborrowed time in a lot of
instances, and working towardsmaking sure we know what goals
(40:14):
are for patients and we'rere-evaluating those goals.
We have our palliative care team, which I haven't really talked
about yet.
They are absolutely tied veryclosely to our patients and our
program.
They see patients multipletimes a year at their first
implant discharge visit in theclinic.
We talk about goals, we talkabout their quality of life,
(40:37):
because the mode of death withan LVAD also changes because you
have a device helping circulateblood, and so even having the
conversation about surroundingdeath changes a little bit
because you have this device andeventually you need to shut it
off and that's really tough.
It's tough on families,patients, the caregivers, the
(41:02):
bad coordinator team whosometimes has to be the ones to
do it, when all you've beendoing for years sometimes is
trying to keep this pump workingand then you say now is the
time we need to turn it off, soit is a tough process to go
(41:22):
through.
Speaker 2 (41:24):
Yeah, You're into exercise.
Is that part of what?
Speaker 3 (41:28):
helps you with this or.
Yeah, yeah, I um, I likeexercising, I like to take care
of myself.
I think working with thispopulation you just um for me it
, it helps me get that releaseif I need it.
Um, I have a daughter, I have athree-year-old who I absolutely
am in love with and you know,becoming a mom and a parent has
(41:51):
really made life that muchsweeter for me, and so I tell my
family and tell my husband allthe time.
I get the dose of reality ofwhat life can be like if I
wasn't so healthy or if myfamily wasn't so healthy every
day, and I'm so thankful when Igo home to have that.
So I think your perspectivechanges a little bit.
(42:13):
When you take care of thispopulation day in and day out
and you see these highs and yousee these lows, it just helps
all the other life minutia goaway a little bit and understand
gratitude yeah.
Yes, yeah, and the simple thingsright being thankful and
feeling gratitude for littlethings that you wouldn't
(42:35):
normally take for granted if youwere, maybe a banker or
something like that.
Speaker 1 (42:41):
Well then, anything, I you lightly touched on some
research you're doing which youcan't, probably can't talk much
about, but like, what are somemore exciting developments you
see coming for this space?
Speaker 3 (42:58):
Yeah.
So I think industry.
You know we're in this part ofour industry where we have one
pump available right now, oneLVAD available.
I would love to see acompetitor come out because I
think when you have two pumpsyou're you're always driven to
do better, so that would begreat.
There has been talk ever sinceI started working in the
specialty about having a fullyimplantable LVAD so you take
away that nasty driveline thatcan get infected.
(43:20):
So I know there's work on highlevels with industry that are
working on those types of things.
Some of the most excitingresearch I've been involved with
is very simple things that havenever been published in this
patient population.
So we did a study a coupleyears ago now looking at how to
optimally check a blood pressurein a continuous flow physiology
(43:42):
patient and we got it publishedand it's widely successful.
Simple things like a vital signis still not fully published in
our patient population, becausethings are just starting, you
know, to develop and technologycontinues to change.
So some of that is very simple,but it's extremely meaningful
and it makes a huge impact onpatients, because high blood
(44:04):
pressure can cause stroke and soif we're not managing it
appropriately or checking itappropriately, that has huge
patient implications.
So there's a lot to be done, alot of research that needs to be
done.
Well, that ends on it.
Speaker 2 (44:19):
Yeah, well, and on so many other things too.
Thank you so much for joiningus today.
This was tremendous.
You just you pulled back thecurtain on the VAD program.
I think in a lot of ways thatour listeners are going to be
able to understand whetherthey're referring patients to
our program.
They understand now a littlebit more about what the patients
(44:39):
are going to be going through,and for patients too, and for
staff members who are listeningin, to understand this really
central part of UW cardiologyand the ways that you've served
people who are really otherwiseat the very end and you are
giving them extra time.
It might be borrowed time, butit is extra time.
You do it with compassion andwisdom and a holistic sense.
(45:01):
I think we owe you a huge debtof gratitude, actually.
Speaker 1 (45:06):
Thank you 100%.
Well, and can't leave offwithout also talking about your
leadership role and bringingpeople together with the Heart
Failure Conference that we havenow.
Yes, you started it right.
Speaker 3 (45:18):
I was involved in the first one.
Yeah, minutely involved andthen got more involved as time
and years have gone by.
We're really excited to bringreally the region, maybe even
national, international folkstogether to talk about all
things heart failure.
Our next meeting is going to bethis coming year.
(45:39):
Do you have the dates, john?
Speaker 1 (45:41):
February 21st and 22nd.
Thank you.
Thank you so much.
Location TVD, but we have it onthe calendar.
Speaker 3 (45:47):
Yeah, we'll have more information out, but we'll
really be talking about allthings heart failure, advanced
heart failure therapy,cardiogenic shock management.
We'll have surgicalrepresentation, cardiology,
interventional cardiology andallied health.
You know everyone's involvedand we'd be happy to have
everyone and host everyone tohave some great conversations.
Speaker 1 (46:11):
Fantastic.
Look forward to it all.
Thank you so much for joiningus today.
Thank you for having me today.
Really appreciate it.
Speaker 2 (46:16):
The only thing that I will say now is don't let this
be your last podcast.
Speaker 3 (46:19):
That's right?
I hope not, that's right.
This is Coffee and Cardiology.
Speaker 2 (00:05):
In this podcast, we sit down with a faculty from the
University of WashingtonDivision of Cardiology to
discuss the very latest indiagnostics therapeutics and, as
a special bonus, we ask whatmakes our cardiologists tick.
We are so very pleased to haveJennifer Beckman join us today.
(00:28):
We have actually been trying toget her on Coffee and
Cardiology for a bit of time andI'm really glad that the
schedule has actually worked outto invite you in here, jennifer
.
You have some interesting andunique roles here at the
University of Washington, butbefore we get into those, tell
(00:49):
us about your journey to thisplace that you're at right now.
Speaker 3 (00:55):
Yeah, thank you.
Well, thanks for inviting me tobe on the podcast.
I feel honored.
It's my first podcast ever, sohere we go.
Speaker 2 (01:03):
We're honored actually.
Speaker 3 (01:15):
So I started my medical journey about 17, 18
years ago.
I decided I want to become anurse and was in nursing school
and became a nursing assistant,and the only job that was
available in the hospital Iwanted to work in this was in
Wisconsin was on the cardiology,cardiothoracic floor, and so
that was where I first took careof patients that just had
surgery or were at heart failure, had heart attacks, those types
(01:38):
of things, and immediately fellin love with the population.
After I graduated from nursingschool, I was a bedside nurse
for a few years and then wasrecruited to be their VAD and
heart transplant nursecoordinator, and so that really
took me much further into thespecialty which I am still
(01:59):
working in today, which is great.
And I further fell in love withthe population, which is great.
And I further fell in love withthe population.
I got a very broad sense of howto take care of patients at the
end stage of their heart failurejourney, and the program that I
worked in was very small, andso I fulfilled not only the
clinical duties but I alsohelped really grow a program and
(02:21):
understood things from aprogrammatic hospital building
standpoint, which is it's a lot.
There's a lot to entail allthose details.
So then I decided why not goback and become a nurse
practitioner while I was busydoing that and went to school,
(02:41):
became a nurse practitioner andwas recruited out here 10 years
ago this July which is timeflies when you're having fun and
I joined University ofWashington 10 years ago and
worked clinically this wholetime and then started really
working on my leadership skills.
The last five, six years havedealt into quality in our
(03:07):
program and then last fall tookover as the associate director
of our program for mechanicalcirculatory support.
And just having a blast, havinga blast, I love it.
Speaker 2 (03:19):
That is fabulous, and it strikes me that the roles
that you have played even, itsounds like, from really early
on in your career, haveincorporated not just the
clinical work but also asignificant administrative role
in this, what is now aburgeoning and, dare we say, a
(03:40):
fairly well-established field.
But when you first got intothis it probably was very much
in the building phase.
Speaker 3 (03:47):
Yeah, absolutely.
When I was a staff nurse, ourLVADs, our left ventricular
assist devices, those were stilldevices that didn't last very
long.
It was the XVE pumps which ifyou got a year to a year and a
half on support, you were luckyand only for bridge to
(04:13):
transplant for those patients.
And you know, I saw HeartMate 2come out, I saw HeartMate 3
come out, the HVAD pump, and soour technology has grown so much
in the last 10, 15 years andit's been just wonderful to be a
part of it and to be a part ofreally changing a program along
with the changing technology hasbeen really special to be a
(04:34):
part of, and so some of theother work.
I've done some research as wellwith our clinical engineering
team and it's just fascinatingwhat we can do from that type of
research to say, okay, how canwe better manage these patients
with our current pumps and whatideally would be a next
generation pump that would workbest for our patients?
Speaker 2 (04:58):
Yeah, you've sort of grown in your career along with
this really rapidly changingthing.
But I would guess it takes abit of a special person, maybe
even somebody who's flexible, tobe able to kind of morph your
career and your focus along withthis really rapidly changing
technology.
Speaker 3 (05:17):
Yeah, I don't know if my husband would say I'm a
flexible person by nature, butthank you for that, jim.
No, I think I have a veryorganized mindset, and
especially so in my work life,and so you know the type A
personality, self-driven type ofmotivation.
(05:38):
That's definitely how I woulddescribe myself, and I think
when you're jugglingadministrative and clinical
duties in a super sickpopulation, you have to be ultra
organized, and so, thankfully,I found a path for myself that
highlights those attributes,which helps being successful.
Speaker 2 (05:57):
Well, tell us a little bit more about kind of
your administrative roles ingeneral and maybe even some of
your clinical roles, because youare an administrator for a lot
of people who are on the frontlines as well as doing frontline
work yourself.
What is it like to actuallysort of supervise people who are
caring for patients onmechanical circulatory support
and care for these patients?
Speaker 3 (06:19):
Yeah, well, I think to take a step back.
When I was approached to domore administrative work, you
know, in the past few years itwas very important to me to
maintain my clinical competenceand I think you know there's a
lot of leaders in healthcare whothey have to leave behind their
(06:40):
clinical work just because ofthe work they do and it's
full-time work and it was veryimportant to me to not lose that
, first and foremost because Ilove taking care of patients.
It's what gets me up in themorning, it's what got me into
this job in the first place,this career, and I still find
huge value in talking topatients and taking care of them
and making them feel better,and so for me that was very
(07:04):
important and I'm very happy andlucky and blessed to be able to
do that with a leadershipadministrative role here.
So I think working with peoplewho are also taking care of
patients when I have myadministrative hat on is helpful
because I can see areas ofimprovement very quickly,
because I'm boots on the groundwith them, so I can see where
(07:26):
maybe there's gaps.
That I had a blind spot in froma programmatic standpoint, that
I didn't know it was there, andso it's helped me be able to
move things forward.
I'm hoping in a positive way forthe program because I am seeing
what's going on on a day-to-daybasis and from an
administrative standpoint.
There's many things that I'vebeen doing, but I think the
(07:49):
biggest thing is I help manageand maintain our Joint
Commission certification for ourprogram, and so CMS.
You have to have acertification body for a program
like a Mechanical CirculatorySupport or LVAD program, and so
there's many, many things youhave to prove to the Joint
Commission on a yearly basis,and then there's an every
(08:12):
two-year on-site visit that youhave to host and prove that you
are doing things and havingcompliance and following their
standards and your own hospitalstandards.
And so I had my first on-sitevisit that I really helped
manage this past January and itwent very well and I was very
relieved to have it over withand understand the process a lot
(08:35):
more.
So that's a huge part of myadministrative role with the
program.
Speaker 2 (08:40):
Absolutely.
It strikes me that it reallydoes take a village to take care
of a VAD patient, that this isnot something that is done by
one person, but the VADcoordinators are really kind of
the ones who are boots on theground, who are front and center
(09:01):
, with whom nothing else isactually going to happen.
But maybe you could talk aboutthat structure, because it's a
little bit different, I think,than other parts of healthcare
that our listeners might be usedto.
Speaker 3 (09:12):
Yeah, yeah, absolutely we.
You know LVADs are so special,even 15 years after you know,
more than 15 years after theywere created, that we really
need to have a team of expertsnursing experts that are there
for the patients 24-7 ifsomething should happen.
And that's what our bagcoordinator team is.
(09:33):
They are wonderful, excellenthuman beings.
I couldn't have a better teamhelping take care of this
population.
We have four full-time bagcoordinators here and they
really help and support patientsstem to stern.
Once an implant goes in, theyare there, they're in the OR and
they're with them in the ORwhen the VAD gets turned off, if
(09:54):
they have a transplant andthey're on the phone with
hospice end of life, they'rereally there, stem to stern, in
hospital, out of hospital.
And I think it's very importantbecause there are things
medically that could be going onwith a patient with an LVAD
that could be related to theLVAD or they could be completely
(10:14):
unrelated, but because theyhave an LVAD, we really need to
have a clearinghouse of makingsure patients are being taken
care of appropriately.
They're on blood thinners, sowe need to make sure that if an
intervention needs to happen,that we don't stop blood
thinners, so they're really thesafety net for the patient and
they get to know them extremelywell.
They know their spouses andcaregivers, animals, dogs, what
(10:37):
have you.
They know them so, so well.
And again, this is part of whatbrings me joy in this
population is you really developrelationships with our patients
and their families, and the VAGcoordinators even much more so,
because they're their firstphone call if something's going
wrong.
They talk to them in the middleof the night, on the weekend,
during holidays, christmas time,whatever, should there be a
(10:58):
problem, and so we couldn't dothis work without them, and they
are just wonderful.
Speaker 2 (11:05):
I have to say that that is absolutely true.
So I still get some of theemails from the mechanical
circulatory support program andwhen a patient passes away, the
level of detail that is shared,you know, confidentially in that
email and this is aconfidential group, it's not
like this, you know, goes out toeveryone.
But the personal description ofthat email and this is a
(11:26):
confidential group, it's notlike this goes out to everyone.
But the personal description ofthat patient, the personality
of the patient, that comesthrough.
It's beautiful to read thatactually, and I don't know that
many other VAD programs andmaybe that happens everywhere,
but my impression is perhaps alot because of you.
But my impression is perhaps alot because of you.
This is the character of thisprogram.
(11:46):
It is not just one that'stechnically excellent, it is one
that actually sees the patientsfor who they are.
They're not a machine.
Certainly you may have amachine in them, but they are a
person and I think you guys do agreat job of holding that up.
Speaker 3 (12:01):
Thank you, thank you so much.
Yeah, I, I personally I alwayscare for patients like they're
my loved one dad, mom, grandma,grandpa, whatever, sister,
sibling, and I hope that's youknow.
It's patients first,patient-centered care, and
that's what it should be.
And so I think, especially withend-stage heart failure, we can
(12:22):
do so much for patients withall the devices and I mean you
know this, jim, with yourethical hat on there's so much
that we can do.
It's really hard for our teamto just, especially at end of
life, for patients to step awayand say, okay, enough is enough.
We know it's time.
And so having someone thatpatients can recognize, either
(12:44):
in the hospital or on the phonefor their family or the patient,
is so special and it justbrings that patient's journey to
an end in such a beautiful,respectful way.
I hope we never lose that inour program With you leading.
Speaker 2 (12:58):
I don't think let's wind the clock back a little bit
on the patient experience too,because one of the fascinating
things that I find is sitting inand I haven't done this for a
while, I need to go back to thisbut sitting in on the selection
committees.
There's such a fascinatinginterplay.
As you are sitting there tryingto figure out who should
(13:22):
receive these devices, what arethe issues that play into it,
maybe you could tell us a littlebit.
Bring the curtain back a littlebit.
Tell us about what goes on inthose I guess you could call
them selection committeemeetings?
But, it's a little bitdifferent than that, even.
Speaker 3 (13:35):
Yeah.
So those meetings are where wetake any advanced heart failure
patient who needs advancedtherapies and we bring them to a
group of our specialtyclinicians so there's probably
50, 60 people that participatein these and we really look at
patients, stem to stern and saywhat advanced therapy options
would fit that patient best andwhat would serve them best in
(13:59):
the future.
And so in this day and age,with how the world of transplant
is and MCS, it's changed a lotin the last five years or so and
it's been really interesting tosee that dynamic change.
But I think the most importantthing is really looking both not
(14:20):
only medically butpsychosocially which patient may
best fit which therapy.
And so because of the specialtyfolks that we have in the room,
we're really able to look atthat from the ground up and make
sure we're making a greatdecision for the patient.
So I don't know how much backof the curtain work.
(14:43):
I can tell you, but thediscussions can be very lively
and sometimes it takes multiplemeetings to come together as a
team to decide yeah, this is thebest option for this patient.
Our VAD coordinators ifsomeone's going to potentially
have a VAD, they are involved.
They do education with everysingle potential patient to make
(15:04):
sure patients are making thebest decision, that they have
all of the necessary informationto make a decision, which is
very important because I thinkwhen you're talking about LVAD,
it's scary and people Googlethings and they shouldn't, and
they see things on the internetand they might not have all of
the information to make a gooddecision for themselves either,
(15:25):
and so we definitely have ourteam involved right away.
Even if you know we think, yeah, they're probably going to go
for a transplant, we get theminvolved right away.
Speaker 1 (15:34):
You talked a little bit about those changes.
So, pulling back that curtain alittle bit, what are some of
those big changes you've seen inkind of how you guys make
selection?
Speaker 3 (15:46):
Yeah, well, in 2018, the UNOS heart allocation system
changed and really that changedthe face of LVAD programs,
because having an LVAD was youweren't getting as priority for
transplant listing, and so youwere able to transplant patients
who have short-term MCS devicesinstead of durable MCS devices
(16:06):
much faster, and so ournationally this is published
data the LVAD implant numbersare quite low after that change,
and so the face of how to treatpeople is just a little bit
differently.
There are certainly those folksthat need a different therapy
before a transplant, and that'swhy we have LVAD therapy for
(16:28):
sure, or age is a preclusivedecider with them.
Speaker 1 (16:35):
So, yeah, and when your voice is in all of that
conversation, I mean obviouslythere's maybe advocates for
different therapies but how do?
You feel like that?
Speaker 3 (16:47):
voice is heard in that process.
Sometimes patients.
It's very clear we should begoing to transplant In those
patients where either transplantor LVAD could be an option.
That's where we start talkingabout more nuances, like how is
(17:09):
the ease of the patient gettingback to the hospital, because
with an LVAD you need to comeback to the hospital very
frequently.
Do they have great socialsupport?
Is there a caregiver lined up?
Is there a backup caregiverpotentially lined up?
Because these patientstypically need support for a
little while.
It's very similar to transplantbut a little bit different.
So we just try to weigh eachaspect of patients and then
(17:32):
medically, there's reasons whypatients aren't great LVAD
candidates as well.
So for an LVAD, you need alarge left ventricle for the
LVAD to fit appropriately andyou need a right side of the
heart that works well.
So if those aren't the case,then LVAD therapy isn't a great
option either.
Speaker 2 (17:52):
What are some of the other considerations in LVAD
candidacy?
Speaker 3 (17:57):
Yeah.
So a big enough ventricle isneeded.
A right side that workssomewhat well is needed Not
perfectly, but somewhat well.
They need to have socialsupport.
I think medically that's reallythe big two things that you
need to have a patient be wellsupported on an LVAD.
And then really it's justlooking at comorbidities,
(18:18):
because usually patients whenthey get to us they've been
through everything mitral clips,a lot of heart failure meds, a
lot of hospitalizations.
They probably have pulmonaryhypertension, which isn't a
problem for our population.
And then really the right-sidedfunction is a huge problem
because if it's not working well, then the LVAD you're going to
have a lot of problems managingthat patient longitudinally and
(18:41):
then just making sure that theycan come back to the hospital
for readmissions if they need it, and then a lot of clinic
visits and testing.
Speaker 2 (18:49):
How about kidney disease?
Speaker 3 (18:50):
Yeah, kidney disease, thank you.
So end-stage kidney disease isa problem, so having a patient
who requires dialysis on LVADtherapy is a very big challenge
for us.
There's a lot of dialysiscenters in the area that are
nervous about taking someone onan LVAD because their blood
pressure isn't like a normalperson's and they require more
(19:14):
training, and so if someone's ondialysis, that's typically
quite a barrier for us currently.
Speaker 2 (19:21):
Yeah, and that's really too bad because a lot of
them actually are either neardialysis or actually on, and
that would be.
That's a population that can bevery stabilized, because that's
a problem for transplant too,right.
Speaker 3 (19:34):
Yep, unless we can do a heart kidney transplant.
But yeah, that's absolutely,and we have taken patients.
Sometimes it's hard to know iftheir renal disease and
dysfunction is related to theirheart failure, and so if you fix
the heart failure, you maysupport their kidneys a little
bit better.
And so we've taken somepatients who've had pretty
decent kidney dysfunction andlargely they've done okay.
(19:57):
Some needed dialysis in theshort term and then were able to
get them off prior to discharge, but yeah, that can definitely
be a barrier as well.
Speaker 2 (20:05):
How about bleeding issues.
Speaker 3 (20:08):
So all patients on LVAD therapy need
anticoagulation with warfarin.
There was actually a recenttrial that was published last
year called the ARIES trial, andthe ARIES trial looked at if we
really need aspirin or not forour patient population with the
HeartMate 3 LVAD, and the ARIEStrial looked at if we really
need aspirin or not for ourpatient population with the
HeartMate 3 LVAD, and the trialshowed that technically you
don't, based on their end pointsof the trial, and so
(20:31):
programmatically we made adecision that any new HeartMate
3 LVAD patient was not going tobe started on aspirin and
they're just on warfarin, whichis a huge change for the fields
worldwide, big change and so.
But there are problems.
So if patients aren't able totolerate anticoagulation with
(20:51):
warfarin prior to, or if theyhave significant bleeding events
, we definitely need to look atthat prior to an LVAD implant
because they certainly willprobably have bleeding events
after the fact.
Same with.
You know, if patients haveongoing cancer history, anything
that would enhance theirbleeding or clotting risk, we
need to look at and we usuallytalk to our hematology oncology
(21:15):
partners about those patients tosee if we think we can safely
support them.
Speaker 2 (21:20):
But it sounds like having cancer is not a
contraindication necessarily.
Speaker 3 (21:23):
Not necessarily.
Yeah, surprisingly, we havepatients right now who have
active cancer right now withtheir LVAD.
I think it depends on what kindand how aggressive it is, and
that's why we always haveoncology involved to help us
decide.
Are we going to be benefitingthe patient by supporting their
heart if they have an ongoingcancer, if their life risk is,
(21:47):
you know, if it would make senseto move forward with that?
Speaker 2 (21:51):
Yeah, how about psychiatric disease?
Speaker 3 (21:54):
Yes, a lot of psychiatric disease.
Like I said before, when we putan LVAD in a patient, we really
own that whole person, and thatincludes psychological diseases
and supporting them from apsychosocial standpoint
afterwards.
So, yeah, we have patients whohave addiction medicine concerns
(22:18):
, who are actively usingsubstances that go on to therapy
, that we need to support.
We are very fortunate we havean addiction medicine program
and team here at UW that helpssupport our patients and sees
them after their implant, andthen we also have a psychiatrist
(22:39):
as well now, which is wonderfulfor our patients.
We also have a support groupfor LVADs LVAD patients and
their caregivers and we'relooking at trying to expand that
in different ways to supportthe patient versus their
caregiver a little bit.
One of the things we know isthat caregiver burnout and
stress is very high.
(23:00):
It's actually higher thanpatient stress level because
that caregiver feels this huge,immense responsibility to keep
their loved one alive, and so wereally want to focus in the
future that's one of our points.
Moving forward as a program isto help support the caregivers a
little bit more.
Speaker 2 (23:19):
Why is it so stressful for caregivers?
Besides, this whole issue ofsomebody's life is dependent on
a pump.
What does the caregiver?
Actually have to, which is badenough, I totally get that, but
what is the?
Yeah?
What sort of stresses docaregivers?
Speaker 3 (23:36):
experience, I think you know the education that
patients and caregivers get isvery robust, and I think they
just worry they're going to dothe wrong thing in general.
So you have the electricalcomponents, which is scary
enough, and then you have all ofthe medication and all of the
different timing, and it's a lot, and there's a lot of changes
(23:58):
up front, and then patients areusually debilitated, so they
have a physical need ofrehabilitation when they get out
of the hospital.
And then we have the littlething known as the driveline,
which is the electrical cableexiting the abdomen which
connects the computer or thecontroller of the device to the
rest of the pump, and so thatexit site.
(24:20):
We stress very seriously thatif it gets infected it could be
a very serious event for thepatient.
And so I think we stress all ofthese things and the patient's
still in a recovery phase andit's falling on the caregiver to
really be on it with all ofthese things.
(24:40):
And really when they get homethey have to come and see us at
least once a week for the firstmonth and then every other week
for a few months and thenmonthly thereafter, and so it's
a lot for someone to manage, andthat's if it's just the two of
them, if they have children athome or if there is other
dependents.
It's a lot to put on someone.
Speaker 2 (25:00):
So they have to drive the patient too, right?
Correct Can patients drive withan LVAD.
Speaker 3 (25:05):
They can drive after about three months.
We just want the sternotomy toheal, but after that we do allow
.
As long as they're stable andthey haven't had any dizziness
or symptoms where we think therewould be an issue with driving,
we do allow them to drive afterthree months.
Speaker 2 (25:21):
Wow.
Speaker 3 (25:22):
Yeah, that's neat though.
Speaker 2 (25:24):
Well, I mean a lot of patients with LVADs do return
to some semblance of normal life, right?
Speaker 3 (25:30):
That's the goal, that's really the goal of the
therapy and that's what we tellpeople.
It does take a while for theirheart failure symptoms to get
better after VAD, especially ifthey've been dealing with heart
failure for many, many years.
I usually quote people at leastsix months when they get out of
the hospital to where they startturning a corner and feeling
better.
And I always just remind themthat they've been in heart
(25:53):
failure for so, so long thattheir body needs time to really
recover once they have goodblood flow through the rest of
their body.
And so we have patients who aretypically they come in and they
are frustrated because they sayI have good blood flow through
the rest of their body.
And so we have patients who aretypically they come in and they
are frustrated because they sayI have good blood flow, I
should be feeling better andmore energetic.
And they just forget thatthey've been through a major
operation and have a lot ofrecovery phase and we send
(26:17):
people to cardiac rehab.
Everyone goes to cardiac rehabto get functionally a little bit
more rehabbed quicker.
But yeah, it can take quite awhile for that recovery phase to
happen.
Yeah, I can imagine, andprobably everybody's a little
bit different in that too, butour goal is that they're able to
(26:37):
do things that they lovedbefore, aside from getting into
water or doing rugby.
Speaker 2 (26:42):
No more competitive swimming with an LV.
Speaker 3 (26:45):
No swimming, no hot tubbing, no bathing in the
bathtub.
But yeah, other than that, likeif patients want to travel, we
really try to make it availableto them.
There are high risk things thatwe don't want them to do, like
boating in case they would fallover in the boat, or motorcycle
riding really mitigating risk ifat all possible.
(27:08):
But they've had a new lease onlife.
A lot of the times thesepatients would not be alive
within a year, typically if theyhaven't gotten the therapy, and
so we and me personally, Iencourage them to do things that
bring them joy, plan thingsthat bring them joy.
You know, I usually ask in myclinic visits what are you
(27:29):
planning?
Speaker 2 (27:30):
That's something you're going to enjoy.
Speaker 3 (27:32):
Are you going on vacation, you're going to see
the grandkids?
You know what are you going todo.
That'll bring you, bring youhappiness.
Speaker 1 (27:40):
How do you balance that conversation when there may
be just still being evaluatedthat like there is all this
optimism and you know you couldhave this many years and you
could be doing these thingsafter your surgery versus I mean
complications or not getting atransplant or whatever it is
like?
How do you balance that?
Speaker 3 (27:59):
conversation?
John Michael, that's anexcellent question.
It's really tough because ifsurgery and recovery goes well
and patients take care ofthemselves, typically they do
really well, but complicationshappen all the time.
We haven't talked about stroke.
Stroke is the biggest, mostscary thing patients ask me
(28:23):
about and ask our team about isa debilitating stroke, and they
do happen.
They're rare but they happen.
So you can have all theoptimism in the world but we do
tell people that they are atrisk for readmissions, a stroke,
bleeding issues, right, heartfailure.
(28:44):
We do have to have thatconversation, yeah, and it's
tough when you have thosepatients who you think are going
to sail through and do reallywell and then it doesn't happen
and they're in the hospital alot or they're just not feeling
well or they get an infection.
It's tough, it's really tough.
It's tough for us as the teamtaking care of them, but we're
(29:08):
not in their shoes.
And so there's been some work,some qualitative work, looking
at if patients could do thisagain, would they?
And we actually asked thatquestion in our.
We do a quality of lifeassessment for our patients and
it's really interesting whatpeople say.
There are patients where Iwould look at them objectively
(29:30):
and say oh, this is someone inthe hospital a lot, or they've
had this serious complicationand I would think maybe they
would choose not to do this andthey do.
And you talk to them about itand they say well, I've had two
Christmases with my family.
Of course I would exchange allof this hardship to get more
time with them.
And then you have otherpatients who maybe are doing
(29:51):
seemingly well and they said Iprobably wouldn't have done this
again in hindsight.
So it's really tough thoseconversations, and you never
know what someone's willing tobasically put up with to get
more time in this life.
And it's not for us to judgeand it's not for us to try to
quantify for them.
It's for us to give informationand for patients to make their
(30:14):
own decision and then for us tosupport them as much as possible
after the fact.
Speaker 2 (30:19):
That is such a key point to make.
It's so hard to predict whatpeople are going to consider
worthwhile.
There's an entire literature ondecision regrets about these
different things, and I haven'tlooked into it for a while, but
it strikes me it's probablyquite similar to what you're
describing is that we can'tpredict what people will say
that they regret or that they'regrateful for.
(30:40):
And likewise there was manyyears ago a study, a randomized,
controlled trial, of PAcatheters.
Of course, in order to get intoit you didn't need one, and so
it was highly skewed in peoplethat you know didn't need them,
but it didn't show any mortalitybenefit.
The quality of life was better,ironically, in the PA catheter
group, which kind of made nosense.
But one of the things he did asa sub-study was actually say
(31:03):
how much time would you tradefor perfect health, and it
varied so dramatically betweenwhen you asked them implant,
when they were in the hospitalin throes of heart failure, and
then after they made it out ofthe hospital later on.
Later on they were willing totrade a lot less time for
perfect health because they werefeeling better, but at the
moment when they're feelingquite poorly, they were willing
(31:27):
to trade more time, but thatshift over time, over months and
months, was really dramatic.
It's very hard to predict howpeople are going to respond to
these things?
Speaker 3 (31:34):
Yeah, absolutely.
And there are folks too.
I see this in a lot of theyounger population but they get
really tired of carrying theperipheral equipment around too.
And so the body imageespecially.
I mean not only the youngerpopulation, I think I see it
more, I hear it more in theyounger patients.
I think after a while they seekgetting rid of that because
(31:58):
they miss going swimming, theymiss just getting up and going.
They don't want to be attachedto things anymore, and that's a
whole different psychologicalmind shift is when you're
dependent on five pounds, fiveand a half pounds of equipment
that you have to always beattached to.
You know you have to sleep withit and shower with it and you
just can't disconnect from that.
(32:20):
And so it is interesting howthings change over time.
And those young patients I seea lot of the times they feel
better faster and they want tojust move on from the therapy
faster.
Sometimes they can if they're atransplant candidate, sometimes
they can't if they aren't.
Speaker 2 (32:36):
Well, that's a great segue.
I wanted to ask you about thedifference in patient psychology
between bridge to transplant orBTT bridge to recovery, which
is rare, bridge to decision,which is even more rare at this
point because we have peripheralmechanical stroke to report
ones support devices anddestination therapy or DT.
Speaker 3 (32:56):
Mm-hmm, that's a great question.
So I think there's twodifferent ways that I see
patients looking at this, andone was just brought to light.
I think when folks are focusedon getting transplanted, there's
(33:17):
always a carrot to what they'redoing.
They always say, okay, I'mdoing this because I want to get
transplanted, or I'm doing thisbecause I want to hurry up and
get listed.
I want to hurry up and getlisted and there's a focus there
specifically towards transplant, and I think that's great.
(33:41):
And transplant is still thegold standard for advanced heart
failure therapy, although thesurvival curves of both LVAD and
transplant are almost verysimilar now, which is fantastic.
But I worry about thosepatients not really enjoying the
time they have and I remindthem that this time that they're
waiting to be listed or gettinga transplant is actually
they're doing amazing work.
(34:02):
They're getting their bodies ina healthier place.
They're going to go intotransplant in a healthier state
and hopefully recover a lotfaster and have better outcomes
from that.
And there is need for that timeperiod on an LVAD if they're
waiting to get transplanted.
But I see a lot of motivationto get listed to get
transplanted and sometimes haveto remind patients that it's not
(34:25):
a free lunch when you gettransplanted.
You're trading a disease for adisease because it's not a fix
to what's going on.
There's a lot that involvespost-transplant as well and
there's complications that canhappen post-transplant as well.
And then you have thedestination therapy group and in
that patient population I wasreminded by a patient recently
(34:47):
who our committee decided youknow what, this patient is not
going to be a transplantcandidate, that's going to be
off the table.
And the patient told me he wasrelieved relieved to have that
limbo taken off of his plate.
And I was like huh, I guess Inever really thought about that
waiting period.
(35:08):
You know, I think once patientsare listed and they have an
LVAD, they're always waiting forthat phone call.
They're always stressing aboutwhen is it going to happen?
They ask me all the time whendo you think it's going to
happen?
And it's like I don't know whenit's going to happen.
But to have someone say youknow what it was, it's actually
a relief to know that this isjust what my life is going to be
like and now I can kind offocus on doing things I enjoy.
(35:30):
It was really interesting to meto kind of hear that
perspective.
But I think for us, for clinicalmanagement, you know, we really
in our program we treat peoplethe same if they're listed or
they're destination therapy.
And I think it's very importantthere's a lot of crossover in
our patient population.
So if they're not a transplantcandidate today, they may become
(35:51):
a transplant candidate if theylose weight or stop using
substances.
But if they relapse orsomething else happens, they may
be destination therapy.
And so we have kind of a yinand yang to this all the time.
But the only thing I will sayis that someone is for sure
destination therapy.
We may not see them as often asthe other folks and so we give
(36:14):
them a little bit longer leash,just a little bit.
But they can call us and youknow we tell them when to call
us if there's problems all thetime.
Speaker 2 (36:22):
That is so fascinating.
There's such an interestingdynamic, especially in when
people are going back and forth,potentially going back and
forth and how your staff you andyour staff have to kind of
manage that.
You're managing expectations,you're personal counselors to a
lot of these patients.
It sounds like you aredispensing wisdom on a regular
(36:47):
basis to help people actuallycope with their lives and thrive
in the situation that they'rein.
But having to hold all of thattogether, it really strikes me
it takes a special individual, aspecial set of individuals, a
special team to be able toprovide this holistic care for
people.
Speaker 3 (37:04):
Mm-hmm.
Yeah, it's truly.
It's not just a cardiologyproblem.
It's, like I said, stem tostern.
It is definitely a holistic wayof providing care and I'm
thankful that we have teammembers now to help us with some
of these things.
It would always be great tohave more support for patients,
and that's why we look at addingmore support groups and things
(37:26):
like that, because even witheverything we offer, patients
still want more.
Some of them still want aVAD-specific substance use group
support group, for instance,was asked of me in the last
couple months or just moreage-specific support groups, so
the younger people can talk tothe younger people about what
(37:48):
they're dealing with versuspatients who are in their 70s
and 80s.
They have a different need base, right.
And so, yeah, it really it's aspecial subspecialty.
Again, that's I love it, that'swhy I'm still doing it all
these years later.
Speaker 1 (38:06):
Well and you are dealing like in this very
interesting place close topotential death and dealing with
that a lot, and you talked alittle bit about supporting
caregivers is a big goal.
How do you support yourself andthe team in thinking of
supporting through all of thatemotional and mental challenges?
Speaker 3 (38:26):
Yeah, yeah, our teams we really celebrate the highs
in our patients and the highsare really high.
You know, getting someonesuccessfully transplanted that
I've known for five years justhappened last week.
It just it's amazing,absolutely amazing.
You know the family.
(38:46):
They hug you in the ICU.
You're so excited when thingsgo well and then you have
patients, alternatively, who youtake care of for eight years,
who die because there's either acomplication or there's a
comorbidity that is bringingthem to the end of their life.
And I think as a team we talkabout it.
We kind of debrief.
(39:07):
If we need to, like Jim wasmentioning, we send out emails
notifying the rest, the broaderteam, when someone passes away.
And that's kind of ourrespectful way of saying goodbye
to that patient because we knowthem so well.
But it's tough, it's reallytough.
Sometimes you just need to sitdown and talk it out and say,
(39:28):
hey, this was really tough.
How are we going to moveforward?
Is there something we can learnfrom this for another patient?
And really, again, end stageheart failure is what we're
dealing with, and so bringingsomeone to that respectful death
is a gift we can give people.
And I think we forget about thata lot, and it's this weird
(39:49):
juxtaposition of we'resupporting someone with a means
that we didn't have available tous 30 years ago, 25 years ago,
even almost 20 years ago.
It's just wild that we can dowhat we do and get people more
time, but knowing, yeah, it isborrowed time in a lot of
instances, and working towardsmaking sure we know what goals
(40:14):
are for patients and we'rere-evaluating those goals.
We have our palliative care team, which I haven't really talked
about yet.
They are absolutely tied veryclosely to our patients and our
program.
They see patients multipletimes a year at their first
implant discharge visit in theclinic.
We talk about goals, we talkabout their quality of life,
(40:37):
because the mode of death withan LVAD also changes because you
have a device helping circulateblood, and so even having the
conversation about surroundingdeath changes a little bit
because you have this device andeventually you need to shut it
off and that's really tough.
It's tough on families,patients, the caregivers, the
(41:02):
bad coordinator team whosometimes has to be the ones to
do it, when all you've beendoing for years sometimes is
trying to keep this pump workingand then you say now is the
time we need to turn it off, soit is a tough process to go
(41:22):
through.
Speaker 2 (41:24):
Yeah, You're into exercise.
Is that part of what?
Speaker 3 (41:28):
helps you with this or.
Yeah, yeah, I um, I likeexercising, I like to take care
of myself.
I think working with thispopulation you just um for me it
, it helps me get that releaseif I need it.
Um, I have a daughter, I have athree-year-old who I absolutely
am in love with and you know,becoming a mom and a parent has
(41:51):
really made life that muchsweeter for me, and so I tell my
family and tell my husband allthe time.
I get the dose of reality ofwhat life can be like if I
wasn't so healthy or if myfamily wasn't so healthy every
day, and I'm so thankful when Igo home to have that.
So I think your perspectivechanges a little bit.
(42:13):
When you take care of thispopulation day in and day out
and you see these highs and yousee these lows, it just helps
all the other life minutia goaway a little bit and understand
gratitude yeah.
Yes, yeah, and the simple thingsright being thankful and
feeling gratitude for littlethings that you wouldn't
(42:35):
normally take for granted if youwere, maybe a banker or
something like that.
Speaker 1 (42:41):
Well then, anything, I you lightly touched on some
research you're doing which youcan't, probably can't talk much
about, but like, what are somemore exciting developments you
see coming for this space?
Speaker 3 (42:58):
Yeah.
So I think industry.
You know we're in this part ofour industry where we have one
pump available right now, oneLVAD available.
I would love to see acompetitor come out because I
think when you have two pumpsyou're you're always driven to
do better, so that would begreat.
There has been talk ever sinceI started working in the
specialty about having a fullyimplantable LVAD so you take
away that nasty driveline thatcan get infected.
(43:20):
So I know there's work on highlevels with industry that are
working on those types of things.
Some of the most excitingresearch I've been involved with
is very simple things that havenever been published in this
patient population.
So we did a study a coupleyears ago now looking at how to
optimally check a blood pressurein a continuous flow physiology
(43:42):
patient and we got it publishedand it's widely successful.
Simple things like a vital signis still not fully published in
our patient population, becausethings are just starting, you
know, to develop and technologycontinues to change.
So some of that is very simple,but it's extremely meaningful
and it makes a huge impact onpatients, because high blood
(44:04):
pressure can cause stroke and soif we're not managing it
appropriately or checking itappropriately, that has huge
patient implications.
So there's a lot to be done, alot of research that needs to be
done.
Well, that ends on it.
Speaker 2 (44:19):
Yeah, well, and on so many other things too.
Thank you so much for joiningus today.
This was tremendous.
You just you pulled back thecurtain on the VAD program.
I think in a lot of ways thatour listeners are going to be
able to understand whetherthey're referring patients to
our program.
They understand now a littlebit more about what the patients
(44:39):
are going to be going through,and for patients too, and for
staff members who are listeningin, to understand this really
central part of UW cardiologyand the ways that you've served
people who are really otherwiseat the very end and you are
giving them extra time.
It might be borrowed time, butit is extra time.
You do it with compassion andwisdom and a holistic sense.
(45:01):
I think we owe you a huge debtof gratitude, actually.
Speaker 1 (45:06):
Thank you 100%.
Well, and can't leave offwithout also talking about your
leadership role and bringingpeople together with the Heart
Failure Conference that we havenow.
Yes, you started it right.
Speaker 3 (45:18):
I was involved in the first one.
Yeah, minutely involved andthen got more involved as time
and years have gone by.
We're really excited to bringreally the region, maybe even
national, international folkstogether to talk about all
things heart failure.
Our next meeting is going to bethis coming year.
(45:39):
Do you have the dates, john?
Speaker 1 (45:41):
February 21st and 22nd.
Thank you.
Thank you so much.
Location TVD, but we have it onthe calendar.
Speaker 3 (45:47):
Yeah, we'll have more information out, but we'll
really be talking about allthings heart failure, advanced
heart failure therapy,cardiogenic shock management.
We'll have surgicalrepresentation, cardiology,
interventional cardiology andallied health.
You know everyone's involvedand we'd be happy to have
everyone and host everyone tohave some great conversations.
Speaker 1 (46:11):
Fantastic.
Look forward to it all.
Thank you so much for joiningus today.
Thank you for having me today.
Really appreciate it.
Speaker 2 (46:16):
The only thing that I will say now is don't let this
be your last podcast.
Speaker 3 (46:19):
That's right?
I hope not, that's right.
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