Drs. Heywood, Kim and Rogers review real-life cases from their practice and answer questions from course participants.
So a couple of questions that are coming through here for dr Rogers, how much role do you think insurance company has to do with race? Disparity in these implants that you talked about is the first question. So that's a great question. And I would say that um when that has been looked at as far as socioeconomic factors and included in that as some look at Medicare and insurance and things like that, I would say that that that's probably the least factor as far as contributing to the disparity as far as an insurance company not approving somebody based on their race or gender. Um But I think that if you look at the multifactorial nature of how these disparities um exist, I think that is there a small percentage that could be in that play? It's hard to know exactly because how was the documentation of each physician or other health care professional that submitted that documentation for approval? How well do they do it documenting what the indications were? I think it's probably from an insurance standpoint. I think it has to do more with that than it does with a racial or gender difference. You know, john there was a study where I think this was admit american heart institute. They just put a reminder in the medical record. If somebody has a low ef, it said maybe this patient should get a defibrillator CRT. Could you, what do you think about that? And you could, you could click three things you could say this patient's demented. They should never get it. Or I'm tight trading meds. And if you said that, then you got a reminder again in six months or you can just click it and it got sent to a clinic for a nurse practitioner to evaluate and when they did that, it really reduced both gender and racial disparities. Just reminding the clinician to do something. I think that's one of the big problem. You know, we have so many things on our mind. We we just don't remember what we're supposed to do and if you could use the medical record to help remind us about what we're supposed to do that could help. You know? I think that that's true and I think another important point which is really unintentional is you know depending on what part of town and what area you work in even though necessarily the insurance company is not making a decision for you. I think we've all experienced for example were relieved when a patient has Medicare or some type of insurance that doesn't give us as much trouble as certain private insurances or even medical for example with our some of our you know a lot of younger women just sometimes don't have insurance for whatever reason. And when you become pregnant you get this emergency medical which is great and they get covered for their pregnancy related issues. But a lot of times I've personally run into trouble getting echoes and things that I need. Um specifically heart monitors that are longer than holders. Um A lot of insurance companies still are a little bit behind on recognizing the difference between A. M. Ka 30 day monitor and a patch monitor and a halter. And so you know I've had to get on the phone and do appear. It appears I've gotten a lot of denials from um some insurances which um for lack of a better way of saying this our insurances that are more seen in minorities, ethnic disparities, that type of thing just because of where people live. So although I think it's an unintentional thing that may point a little bit to what you're seeing. It's not so much that the insurance doesn't cover it, but different insurances have different criteria and different populations gravitate towards those types of insurance is based on where you live and that may play a little bit of a role. I see another question here for dr Rogers. We talked about the, you know, I think we talked about short stature. It says, why do you think there is disparity in height as to the results with CRT or by V. Um that slide you had in there about the shorter men and, you know, shorter women or shorter people doing better if you have any thoughts about that as an implant. Yeah. You know, it's interesting the procedure to implant is the same regardless if you're seven ft tall or you're four ft tall. And, and I think this may be something tom may be able to chime in on here, as far as the hemo dynamics of of the anatomy, of the of the heart, of the chest. It's all the same. We have four chambers. We have cardiac veins, we have distinct rainy and and and what's interesting in the data showing those shorter statute, people actually responding better to see our T with an EF. Excuse me, a QR restoration of even less than 1 30. Them doing better. I think it may have to do with the different pacing vectors that we can use with CRT. Is there a different, is there a difference in the chemo dynamics of a tall stature versus short statured person? I'm not sure I know the answer to that directly, but it somehow probably has to do with that. Maybe we have to ah index QRS to Bs BMI or something. You know. Maybe that would be yeah. Just like I wonder about that myself to like how much of it is just Anatomy versus gender, especially when it comes to something so specific as a procedural DR kim pointed out with Hokum, you know, using the same measurement of the septum and men versus women who have different body sizes doesn't make a lot of sense. Maybe the cure restoration is similar. You wouldn't think so, but at least the data points in that direction, so that's important. Um And it looks like we've got I think one more question question slash comment here for dr Rogers, but anyone can china and it says, do you think that women's survival in CRT with left bundle branch block is because women tend to live longer anyway? Or do you think it's attributable to the CRT or the baby itself? Well, that's a great question. And I'm sure tom may have some thoughts here too. But it clearly if you look at why women have a higher survival is that women tend to have more non ischemic cardiomyopathy, which means there's less dead tissue and more and then more ability for that ventricle to respond to CRT therapy. And so I think that perhaps this multifactorial, like everything we've been talking about, maybe on average women tend to be shorter. We saw that shorter stature is better. Why? We're not 100 sure women tend to have less, not always, but less non ischemic cardiomyopathy. So, you know, the registries and made it CRT and all these studies show that in women with non ischemic cardiomyopathy That they are going to respond to CRT better. The statistics for heart failure, although some, some differences, you know, 50 mortality at five years and some groups of people that have heart failure. So if you improve that heart failure by CRT therapy, they're going to have less mortality and have a better survival. So if they're better responders and I think that contributes to their better survival period, I don't think you could overestimate if you have a woman that's not a scheme eight that has a left bundle, who's ef is 35 when you put CRT and they typically their f goes to 50 or 55%. So uh, you know, they almost don't need medical therapy. They just need the pacemaker. And you know, if you normalize the ejection fraction, it really changes their prognosis. And plus there, I mean, nobody wants to have heart failure and if you can fix it, that's that's the way to go and and often pacing for those group of patients. Often women, you know, we do you know, I'm more optimistic often when I'm recommending a woman for CRT than a man that she's going to have a really good result. That's great. And that that's actually a really great segue into the cases that we're going to do next. Hopefully we'll have time to get to them. I think you've each got one. Um I think if you would like dr Heywood we can start with your case that you had and I think they've got it ready for us in a moment here, fingers crossed. Okay, I think we got does that look familiar? Perfect. Let's say. So this is a 36 year old 70 I'm sorry, 76 year old woman with a history of a fib fib ablation. She's been short of breath for eight months. So when they're short of breath you get an echo, Echo showed a F Is normal. Better pay pressure's 70. So this is really a disaster. Um If you have a normally F and your P. A pressures over 48 not even 70. Ah 50 of those people are going to be dead in three years. So this is really kind of an emergency in this poor woman. So we did a heart cath on her and I'm just going to show you this her right. Atrial pressure was 10 or P. A pressure was seven. RV was 75/10. P. A. Was 75/25 with a mean of 42 her wedge was 16 now in, so she's in kind of a mixed group because you're Typically somebody with pulmonary arterial hypertension would have a wedge of 10, but hers is 16. So she's got a kind of a mixed picture. So what else? What is this? Well, this just shows you that in medicine people can have two diseases and that's what this person had. She had both pulmonary arterial and pulmonary venous hypertension. So, So we had to treat her two different ways. One is we had the diaries her to get her wedge pressure lower, and then we had to give her medications to lower her uh pulmonary resistance. Her would units was three, which normal is about 1-2. So her pulmonary arteries were very constricted. So after we dire East her and we even put in one of these pulmonary artery monitors in her. Um We we gave her uh these Viagra type drug to lower pulmonary artery heart and her PA pressure when we were monitoring at her home, went from 75 to 40 in just about two weeks. So we were able to fix her pulmonary hypertension really in just a couple of weeks. And what was very gratifying is that the pressures have stayed down now for two years and instead of walking only a block, she can walk several miles and even has hired a personal trainer. So, uh two messages from the talks today. One is somebody short of breath. Please get an echo and two, if you see hypia pressures on the echo, we really need to sort out what's causing it and and treat them. The treatments can be very dependent. The the treatments are as varied as the patient and sometimes we use one set of drugs, sometimes another. But the major goal is to get the pressure's down and to help reduce shortness of breath. And I'm going to end there. So that's my case. That's great. Thank you. It's perfect. Um and then I think we can move right on to Dr Rogers case and then hopefully dr kim's and then we can take some final questions if anybody has any lingering thoughts. So hopefully we can pull up Dr Roger slides next. Okay, great. Um This is a case that it comes up not too infrequently in my practice where it's of a special consideration because of differences of anatomy. And it's interesting as I meet women who have been referred for device implantation, pacemaker, defibrillator CRT. One of the things that comes up is them talking about how their physician and other health care professionals were reluctant to refer them for the device because of the fact that they had breast implants. And so this is a patient of mine that I had for many years who uh poses a specific challenge, both with diagnostic monitoring as well as further. And I just want to present it and just discuss the issue that this special population brings up as far as challenges for devices since that was my topic today, This is a 77 year old, delightful woman with recurrent sync api and near syncope. Her episodes occurred every few months. That's a very important point. She has a history of breast cancer and was treated in the 19 eighties with a pretty radical mastectomy as far as um um um treatment for her breast cancer. And then she had reconstructive surgery. She also had radiation therapy to the chest wall, which becomes pertinent as well. In the discussion now fast forward to just a few years ago and the implants that were done at that time as frequently occurs, our body forms a scar tissue capsule around anything foreign. It forms it around devices. It forms it around breast implants. And so these breast implants and the capitalization that has occurred due to scar tissue around them have become very calcified, so very hard, almost rock hard. And the patient was just never interested in having any type of a revision. Her implants were placed sub glandular, which I'll show you the difference of the three different or four different positions that plastic surgeons will place breast implants. But that specific location posed several challenges for her. Now, with the need for diagnostic monitoring and beyond. So when we look at which monitors, we pick just to review if somebody's having symptoms that are occurring more than once a week, 24 hour, 48 hour Holter monitor is fine. If symptoms occur a few times a month, a 30 day monitor, but if their symptoms are occurring more than a 30 day monitor would capture, then it's not inappropriate to go right to an implantable cardiac monitor And per our guidelines, which have been updated as well as 2017 basically, if symptoms are occurring more than four weeks apart, the implantable cardiac monitor is reasonable to start with. And in fact, her primary care physician had put an external monitor on her, but it didn't stay. She was non compliant with wearing it, as are most people. And her symptoms were again occurring every few months, so likely not to be picked up On the 30 day monitor. Note there's no mention of gender here, right? So that's the theme of my discussions. Nothing in our guidelines tells us what we should or shouldn't be doing as far as gender or race goes. So this patient for an implantable cardiac monitor and usually the best location of the implantable cardiac monitor is this position right here, about a centimeter or two away from the sternum to the left and an angle about the fourth intercostal space in about a 40 to 45 degree angle from the sternum. If for any reason, that position is not ideal. Then vertically placed here. Same starting position, but vertically here again. What might not be the good reason for position? Where it's all about? How well does the device with the recording electrodes on either end of it? This is a subcutaneous diagnostic monitor. Um All the pacemaker companies make these Now batteries last about three years. Put it under local anesthetic only to think of it as the little black box from an airplane. When we crash. When people have syncope being, we don't know why these monitors help to rule out an arrhythmia as a cause. Since we can't predict when the sync api might occur in some patients, it's all about how all this, how well the signal of the heart is being detected that are wave and the QRS complex. How well is that being recorded? And that will help us in tacky brady and pause and a fib determinations. But sometimes we run into challenges where these positions aren't adequate. And so we might place to monitor down here. And that blue line, that arc is supposed to represent the underwire portion of a woman's bra because it becomes very important to make sure that we're below that. And as long as we're still getting good are waves, that's a reasonable position to place the monitor. This is that patient and she required a subcutaneous monitor and you can see from her chest that she has uh implants. What you can't appreciate. It is their right below the surface of the skin and they're very calcified and hard. So this position did not, what you can't see is the angular ation of the breast. And so this position would not be good because it would be putting pressure on the subcutaneous tissue. Um kind of rocking back and forth on where her implant is sort of peaked anterior early. You can see a radiation tattoo here from her radiation therapy that she received long ago. And so her skin right here along the sternum itself was very brawny and woody. And I felt that it would not be a good situation for the tiny incision for this to be slipped under for it to heal. What you also can't appreciate or cannot appreciate is the fact that that skin between the breast implants over the sternum is kind of tinted up as well from the stretch pulled by those large calcified implants. And so this other position in her down here was where the location was chosen to place the device. And you can see here making sure that it's well under the wire portion, underwire portion of the undergarment here because we don't want that stiffer portion of the bra rubbing against the monitor itself or in the incision which is here. And this is just showing how this device is implanted under the skin, subcutaneous only and can get away with that And women, what's interesting um I'll call it a male assumption. I had two young women that were very athletic volleyball players um and they both were presenting for different reasons. They were referred for the implantable cardiac monitor. And I said now I'm I'm pretty sure you want it down here below the breast. And we talked about and they looked at me and they said no I don't kind of surprised me and I said okay. And they said when I dive, playing volleyball I land on that area below the breast. And that's exactly where you're talking about putting the monitor. So they actually asked me to have it placed up in the typical position. So they're athletic activities and their sports and what they do also play a role in how we implant these devices. Um and that you know the old dog new trick thing. They taught me something that I can't assume every woman might want it below the breast for whatever reason, cosmetically or for comfort. So nine weeks after the monitor was implanted, she presented with a six second pause. This was not a passing out spell, but it was one of her typical, I almost passed out spells. So the indication for a pacemaker was given. And basically then we have to talk about how to navigate around breast implants. Because her breast implants, we're very close to the surface of the skin being sub glandular. So a sub glandular implant. Here's the rib cage, here's the pec minor pec major. The implant goes above the muscle, below the glandular tissue of the breast. Now a pacemaker would need to be implanted in this region here. So we can see if the pacemaker is implanted here. It's going to be pushed up by that implant. A sub pectoral implant here notice the same anatomy, but the pec major now is on the divide. The implant is placed below the pectoral major muscle. The lower part of the implant is not encapsulated in muscle. But this is one type of sub pectoral implant. It's partially unsuited under the pectoral muscle. Keep in mind. Most incisions for breast implants are coming from the lower pole of the breast here and being put up in here. Whereas pacemakers are being put in from here and put down into the pocket here. This is a completely sub muscular implant where the entire breast implant is placed between the pick, minor impact major and so less situation here if the pacemaker is going right in this region here. But the breast implants were for purely cosmetic reasons. A woman may not be happy with the pacemaker pushing out against the skin because the implants pushing it up hard farther against the skin and subcutaneous tissue. But in our patient that we presented the implant is actually closer to the surface of the skin and the capsule which forms around the implant is very very calcified. And so one of the things that I did as being primarily a device implanted er was I worked with the plastic surgeon of breast surgeon dr aria here at scripts and had her work with me on cases to work to show me the best way to manipulate around the breast implant. The biggest concern and fear I have is actually popping her, deflating an implant or causing a leak or damaging it. Um That's traumatic for the woman to have to go through another surgery. But also the trauma of just that in general something that it was something that was keeping me awake at night as I was being faced with implanting more women with breast implants and we have to do that. So I felt what better way to to work with a plastic surgeon. We correlated our schedules and after a year or so of doing that I felt very comfortable myself and and being able to implant devices either cosmetically or from behind breast implants. So what you'll find is in the patient that I'm describing her. Her implant was sub glandular or subcutaneous placing the device here would have made it stick out quite awkwardly on her chest because of how that implant had become so close to the surface of the under the skin. With not much subcutaneous tissue, a very thin subcutaneous layer. And the pacemaker would be pushed up by the calcified implant and sticking out more, which was not ideal. And so with her device being here, what I was able to do was to place the device sub pectorals muscle, the pacemaker. So actually going uh separating a plane in the pectoral muscle bundles and her pacemaker was able to be put down below the pec major and above the pec minor. And so it's a sub pectoral muscle implant will do that for cosmetic reasons, will do that for people who just don't have any subcutaneous tissue. And we're worried about the incision healing but it's not that difficult to do. But you have to be comfortable doing it as an implant. Or not everybody does said pectoral muscle implants. And so some women could be especially when it comes to larger devices, defibrillators or CRT devices. They could be less referred if their physician, their cardiologist, whomever their doctor is doing the referring is worried that well they shouldn't have it. They have breast implants that may preclude that the breast implants don't preclude it. We just have to know what we're looking at here is your chest X ray. And you can see it looks just like a normal pacemaker. The pacemakers here on the left anterior chest leads go into the vein, there's an atrial lead and a ventricular early going up toward the septum. It's kind a little more anterior septal but this looks like a normal pacemaker implantation. You can see the haze of the very calcified implants here. And the extent of that implant and the calcification of it appearing like that white ghosting in milky area. Um That's the calcification of her implants and what you. It's hard to appreciate her devices located right here. It's under the muscle, on a lateral film her pacemaker. If it was subcutaneous it would be out here right under the surface of the skin. But her breast implant is already pushing that area up so her device was placed under the muscle and had a very acceptable cosmetic result. And comfort result not just cosmetic but comfort because the device would have been pushed up so far against their sub Q. Tissue. So I would say don't avoid referring or implanting devices for women based on the bias of the chest anatomy issue because we can't assume a woman won't want a cardiac device. Well I'm going to make an assumption. She has breast implants. There's not much skin there that she's not going to want this that we cannot make that assumption. Um If you're an implant er of pacemakers, defibrillators CRT and you're hesitant to perform a cosmetic request or you're not comfortable with working around breast implants. Um I wasn't when I started doing this um and for a long time recommended and Planter who is or develop a relationship with a plastic surgeon that you can work together on those surgeries too to do the best implant for a woman with a breast implant. So it's not sticking out and not uncomfortable for them. Um And I encourage you to to to to work with a plastic surgeon to do that and you'll gain the experience to to do those implants yourself. As I did pass it over to NAMI. Do we have time for an army? Okay. Great. Yeah. Um Thank you for that. Great. Really educational. Um um case dr Rogers. Um A lot of things think about and you know, working with their colleagues over in plastic surgery. Um We have uh two quick cases here. Um They just kind of go through what we discussed today. So first case um So they're both my patients. First I've got a 77 year old woman I met for the first time when I started my practice, she had already had history of non ischemic cardiomyopathy with the f of like 20% ish major fibrillation stroke. With very minor cognitive uh dysfunction otherwise. No no residual um um deficits, distant history of colon cancer without any chemotherapy. Uh Pretty label um diabetes and some very stable um peripheral artery disease. So by the time I met her she had already been on optimal medical regimen of carving. The laws are interlocked in Los Artan. She failed and presto um due to low blood pressure is what I was told and was otherwise usually make easily regularly um Just kind of chronically low blood pressure without significant symptoms. Um And she was an anti coagulant appropriately and was a rape control strategy with the Carnival alone. Jackson. Um She had had a bi ventricular pacemaker, defibrillator upgrade six months prior to me meeting her. Prior to that she had a dual chamber for distant history of sick sinus syndrome. And I was told by the patient and the family that she was referred for. An L. VAD, which stands for left ventricular assist device, which dr Heywood and the rest of the cardiomyopathy team are experts in here um at an outside hospital. And she was declined because she lives in a retirement home. And there isn't somebody that you're leaving with her to provide a social support of maintaining Eldad. Um So that's what I knew of her. She's not too active, she uses an electric scooter at assisted living facility. Um But because she's not doing a whole lot, she's not really just next. Um So this was her when I met her um yes, suggestion frank, she's dilated LV. And um she had reduced ejection fraction and um when we interrogate her device um She was only by ventricular early. I mean she's v pacing and by ventricular pacing only 22%. And it was because of her frequent rapid um a few episodes which is completely asymptomatic with. Um So the question was, what is the next step? Um So well we're gonna do the basics. So I made sure she was not anemic that her electrolytes and her kidney function is good. Um And I made sure she wasn't hyper thyroid. Um And it did confirm that, you know, she has ongoing issues with diabetes control there. Um And then so we made some quick decisions. We said you know what, we will attempt to control her right little better by switching her from a very low dose carvedilol that she was on at 3.125 twice a day to Manitoba law will titrate it quickly over a course of just a few weeks. See how she tolerates and you know, she doesn't tolerate. We've got to move on two A. V. Notable ation. Um so that we can optimize or by the pacing and to get the rate under control. Now as as things always happen, you know, sometimes patients just can't catch a break. We went through about six months of hospitalizations for various, you know, medical issues, trans amenities and jaundice from college, Chocolate Diocese coming Ukraine pneumonia, some cellulitis and substance. And because of her diabetes and uh the farc Seaga that she was taking, she was intermittently very dehydrated with hyperglycemia um um and um struggled to get her diabetes under control in part driven by her frequent infections. So we lost about six months while she was in and out of the hospital. But finally, um we finally got her um Got a stable um she was not infected. And so we found a window of opportunity. We had to undergo a v note ablation. And three months after the note ablation, she had almost normalized rejection fraction to 50%. She's walking now. She doesn't need electric, electric scooter anymore and has a lot more energy level that she actually didn't realize she didn't have. So she didn't feel bad, but she didn't realize that she could feel better until she did. So um That was that was a great story. Certainly she avoided having an L. Bed um um um which was contemplated in the past. So that was a great story, kind of going back to our colleagues and dr Heywood about how when our patients really improve with some of our more invasive intervention, it's it's just really good to see. Um All right, so that's kate. Uh and I have one more case for you. This is a recent patient of mine. She comes to see me for history of very brief, you know, occasional little paroxysmal SPT that she feels she has a distant history of gastric bypass surgery, nash diabetes hypertension. Um And I'm seeing her for palpitations. Um She saw a cardiologist seven years ago for palpitations hasn't changed at some point. There's a lot of P. A. C. S. And P. V. C. S. And brief little spurts of SPT not too fast, 140 speeds per minute. So more for symptomatic control. She was starting a total seven years ago. Over the years she she was titrate up 200 mg of material twice a day. And recently recently self titrate id 23 times a day on her own because she finds it bothers them. She says that will make her dizzy. Um It's just irregular, brief little bit of global sensation maybe. Um She gets a little orthe ascetic occasionally but nothing nothing out of the ordinary. And she's a little Disney a but it's not exertion all and she's overweight and she always thought she was de conditioned. So she's on typical medications you know um less than a pro given her diabetes and hypertension history. As I mentioned the top 100 mg three times a day that she's self I traded up to. Um And otherwise her diabetes is Is being managed with the foreman and recently started out at sema glued I um and she comes with significant ischemic heart disease history of her family brother with them. I have 50 father within my age 42. Um And then so I looked through her chart and she had a patch monitor last year more of the same. Eight bits of S. V. T. Which is really nothing that much at all. Um Pcs PVC. She just had a holter right before I saw her that her primary order some more of the same. Very underwhelming. Um But certainly she's bothered by it. Um um She is a borderline hypotensive on her motto. Prolonging listener. Pro her physical exams. Um No significant finding. She is overweight with me and I of 38. Remember she did have gastric bypass surgery 20 years ago and otherwise her borderline anemia is very stable. It's not new. And um her TSH was on the lower side 0.775 But there weren't any major um red flags. This is her E. K. G. Um Overall no urgent findings as far as arrhythmia is concerned. Um So we went ahead in order yet another event monitor and updated the echocardiogram and everything looked okay. Echocardiogram. Concentric remodeling measure. The septum at 1.3 centimeters. Not unreasonable for someone who had hypertension you know in the past And she just had maybe a little bit more more frequent PVCS but certainly nothing outstanding. Um, it was only at three and so I asked her to take some magnesium supplements, make sure she doesn't get diarrhea. You know, she, if her symptoms are very chronic and not to bother them, she should back off on the motto pre law to twice a day and kind of see how it goes. And this is the echo at the time of our follow up. So five months later she's single pies is and she said she was going to the bathroom, she's been vomiting a lot on those epic that she was taking for her diabetes and um, she felt really nauseated. She had just started um, gabapentin and all these other tram inal and other drugs and she also has just started hydrochloric Kaiser for leg swelling. So it just seemed like a perfect storm where she has a little bit of vassal bagel, Some worth a static and some medication side effect. Um At that time she was hypovolemic and the echo was done. And this time there's a mention of systolic into emotion um Of the micro apparatus and there seemed to be a new increased left ventricular outflow tract velocity, resting grant gradients only 11. But with myself I went up to 51. And um and so at this point um we decide um two update yet another monitor and and poor lady torturing her with all these monitors. And then if it's negative given the echo finding, which could be just from you know um you know women smaller hard hypertension history, a little bit of you know um L. V. H. Type of picture in setting up type of bulimia. We decided that you know although there seems to be all the reasons why she could Singapore. Perhaps we should do an implantable monitor loop recorder for long term monitoring. And she was okay with that. So we did and then when she came back afterwards um she told me yet another brother had had another heart attack. Um And as she was doing okay with the blood pressure. Her pleasure was low for a while but had normalized we decided to add wrapping up because of her L. V. O. T. Obstruction physiology. Um And at this point she said like three or more even monitors over the last couple of years now she's being monitored on the implantable loop recorder. And this is what we see one day. Um And we called her and in fact the shocking thing was I had done a video visit with her that morning and I got this alert three hours later that it had happened five hours ago. And when I asked her did you feel anything early this morning? Before I done a video visit? She's like no. And then she's like, well actually I feel a little odd going to the bathroom at five. AM. So it was 46 minutes of non of ventricular tachycardia. Um And the average rate 176 beats per minute. But mastery was 2 40. I'm I'm I believe she felt this um in retrospect when when she started thinking about it, she felt it. So what are the next steps? Well with VT, we always like to rule out coronary disease And of course she has all those brothers and father and everybody who's having M. S. Um dying from M. S. A. Very young age and um um luckily um and she does have diabetes herself, she did not have obstructive coronary disease. So the next thing we did was a cardiac MRI um to make sure she doesn't have any my cardio myopathy that we may have missed on an echo. And interestingly enough um remember on her echo in her initial echo Herceptin was measured at 1.3 centimeters and on a subsequent echo where she was hypovolemic from all that vomiting and hydrocortisone. Guys that we saw some L. Vot gradient. Well on the MRI we found maximal asymmetrical septal hypertrophy of $1.5 million dollars just meeting the criteria for hypertrophic cardiomyopathy. And it is that this hospitalization, she tells me, oh I forgot to tell you that one brother that died of heart attack. I was told that his heart was thick on autopsy. So it turns out that I ended up becoming her one of her living brothers. Cardiologist. At this point I'm seeing the family and her other brother who's living. Actually brought the autopsy report and her and this brother who had died um more than 10 years ago at this point it is is noted by the pathologist, the medical examiner that the LV measured up to 2.2 centimeters in thickness. Um And there was an area of old scarring in the LV apex. Could have been uh what we call burned out Hokum where you can start getting the a pickle scarring after a long time And um and additional coronary arteries to have kind of moderate diffuse at um um cyanosis 60-70 And so after all it sounded based on the autopsy that he probably died of sudden cardiac death probably from VT from cardio hypertrophic cardiomyopathy. So with this new uh new cardiac M. R. I. Finding where she meets criteria for hypertrophic cardiomyopathy. And now with a family member who has died of died of sudden cardiac that she met criteria for a defibrillator implant um for uh primary prevention. So um and that is what she underwent um just a couple of months ago and she's doing well and um now I see um a few of the siblings and everybody seems to be doing well and will be moving forward with some genetic testing. So um that kind of um I think ties in all the things that we cover today. Um I'm gonna turn it over to dr good in here. Thank you. Dr kim. That was really that was wild. That was fascinating case. I'm glad we took the time that you took the time to present that for us. So um we are it's exactly one p.m. so I'm proud of us for sticking to our schedule. I want to take a minute to thank our speakers um all of my colleagues and friends um and mentors uh you know I think we sometimes take for granted what level of expertise we have just because we see each other every day. But I'm hearing these talks, I can honestly say I learned some new things today, you know, things that I thought I should have already known. So I really appreciate our speakers giving their time and energy making these new talks um and spending their saturday with us when you've already got so many other things to do. So thank you to all of our speakers. Um thank you to our participants. You know, this is a passion of mine. You know, we really really like to promote educate and myself learn about heart disease and these gender differences. So part of this conversation is you know, just to to create awareness and for us to talk about these topics. But you know, my hidden agenda is really to get other people interested and maybe even find some people to collaborate with over time. So given that this was our first symposium, such as this were certainly planning and hoping to do more at least a couple of year, we are very open to feedback. So if you have more questions that didn't get answer today, I believe you're receiving our contact information. If you have specific topics or ideas that you would like us to discuss in the future or even ideas that you would like to collaborate with. We would really love to hear that feedback. Um I do want to thank you for taking the time to join us on a saturday when we all know that there's plenty of other things to do and we're probably all very sick of sitting in front of a computer these days. So again very much appreciated and I want to thank our our I. T. Staff and Carlin for helping to organize this. Again you should have I believe access to our slides access to a link on how to obtain your CMi credit and again please do feel free to reach out to any of us. I'll tell you a secret all of our emails. Our last name first name at Scripps health dot org. So if you do want to reach out to us independently um for you know questions, comments discussions please feel free. Please enjoy the rest of your weekend. Thank you everybody please. Mhm. Mhm. Yeah. Mhm. Mhm. Mhm.
