Drs. Mende, Mohan, Rasmusson, and Srivastava address questions from the audience.
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So I think we will move on to uh questions. Um We'll see one question moved over to the chat about any long term data on our a pressure RV pressure and function uh in developing pulmonary hypertension with the shunt. So um there is data from some of the original trials that followed out to two years without any significant increase in in our a size and pressure as well as RV function. Um the amount of shunting that actually occurs is actually quite small. The measured shunt fraction is typically about 1.2-1. So these are relatively small amount of shunting that occurs but enough to help reduce left atrial pressure. And the other thing is that it's dynamic. So at rest there's not really a lot of shunting happening. Um the left atrial pressure is always going to be a little bit higher than the right atrial pressure. And so there's always left to right shunting. And in fact in those patients where the right atrial pressure is a little bit higher, they're they're not qualified. Uh They're they're not candidates for entry into the study because of course we don't want right to left something. So there's always just low levels at rest. And really the interesting part of these devices is that with exercise then as the pressure goes up in the left atrium then the then there's more shunting across the septum. Um And so really not a lot of changes that are seen on the right sided parameters in the data that's available so far for Doctor Mendy. I thought that talk that you gave with spectacular um and it was rich with all kinds of clinical pearls that I think are important reminders um for all of us and taking care of patients with high blood pressure and with or without heart failure. But my question is related to the cameras. Um in our heart failure guidelines and in our articles like the 10 pivotal issues and taking care of patients with reduced ejection fraction heart failure. When it comes to the follow up for spring lilac tone or Applera known we have a very specific prescriptive recommendations for getting a BMP within days of starting, you know, at a week within a few weeks a month and then quarterly long term. And I find it really interesting when I've you know, talked with nephrologist for example, they'll start an MRA in a patient and they won't get a BMP for a couple of weeks. And I just try to understand, you know, how is it that that difference is there and what's your take on that? I mean we we have actually put together we call it spiral labs and a protocol when we start the camera we give it to patients, we get lab scheduled there. You know the patients know they're on our list. Um we're very organized in terms of how frequently we do this because the risk of hyper Colombia. So I just love to hear your thoughts on that. This is interesting. I think you know what you need to look as his first on your baseline. Each of our, if you're, each of our really is less than 45, you know, that's sort of like the threshold. Uh one probably should do a potassium level within 5-7 days. And uh it's kind of interesting that and if it's you know about 45, you know you can probably wait but I still like to get it within 10 days or two weeks anyway. Even people with each of us higher again over the counter use of handsets by itself can cause hyper Colombia. And you will see more hyper Colombia. If you use an inset regularly, let's use two doses day with spirit of lifeboats. So that's another warning. Thirdly, for whatever reason, the people who do develop hyper column, you do so early, they do it in the 1st 23 weeks. And if you don't have any potassium problem, it's unlikely for you a month or six weeks or two months later suddenly develop hyper Colombia unless something changes you took and then set for a couple of days or your each of us has gotten worse. So, so I think the the occurrence hyper Colombia is up front and within each of us less than 45, you know, maybe 57 days is a good time and then maybe for most people 10 or 14 days is a good time to be really on the safe side. I hope that with the data I've seen from Finneran in which hopefully pretty suitable not just extend to cked reduction but also to heart failure of reduction. Um I think that that your risk will be going from six or seven times from an ace inhibitor and a RV with spironolactone down. The only the risk was only double. So you only doubled your risk of hyper Bolivia. So so that scenario would be more selective. Well really cut down on the on the hyper Colombian. It will just have to wait with the heart failure. Data will show it that that with that drop that's interesting to hear because there's a you know, there's as you know dr is music. There's a number of different scenarios where we sometimes use the spironolactone specifically for the purpose of helping with potassium management and the patients that are on higher doses of loop diuretics. Um so it'll be good to have some options, I guess. Depending on what how people, how patients are in terms of their potassium loss with the loop diuretics with wanting to add on some amount of mineral according. Coid antagonism. No cardiologists will appreciate that if you have an M. R. A. On board, you also are regaining magnesium. So, so you that these these all these mrls and and also actually it's true for miller. Right? But the cameras are all the ministry um, sparing there is a significant lower loss of magnesium in the urine even with the Loop Di Ready. And I think there's a question for you from the audience. So you mentioned tele rehab. Do you have recommendations of who you refer uh for dietitian for patients with heart failure um and eating disorders who may need psych evaluation as well. So that's a great question. And something we learned um uh is you know, uh when it comes to this virtual care, you know, whether it's dietitian, whether it's rehab, it's really system dependent and where you are. I mean, so what we're having a script, I mean, we've always had outpatient rehab where patients would drive from wherever and come in um three days a week and do like cardiac rehab, spent an hour and work with the physical therapist um usually covered by Medicare um at least up front for x. Number of visits. And then there's a certain copy involved with that. Um What we're doing at scripts now uh script has recently signed on with this company that does home based physical therapy slash rehab. So it just started rolling out about a couple of months back. So we are now allowed to refer patients to this home based physical therapy rehab program by placing an order um uh an epic um And then they do uh initial intake and then um get the special and role and they give them exercise well they go to their place initially and do an assessment and then give them exercises to do at home and they can do X amount virtually. So that's what's happening over here for home based rehab. Um And that was just started a couple of months ago started with actually the orthopedic procedures and now getting into the cardiac space as well in terms of dietitian flash uh nutritional disorders we have. Um And this has been a problem in general, you know um primarily to do with reimbursement. We have dieticians a nutritionist on the in patient side. We don't have it on the outpatient side. Um for heart failure. Uh You know most of our nurses and a pcs um do most of this education. We have stationary and booklets that we give patients. Uh What scripts is doing now is looking at. Uh Because as you just pointed out there's a lot of value and need for something like this. The scripts is looking at uh uh resources like that, just like home based rehab. Can we offer virtual dietitian therapies? But yeah I really think it depends on the clinic, it depends on the setting and the region um what's available to you. Um It's worth checking with the nearest uh If you're at a clinic may be checking with a larger program um uh see what resources they have that your patients could benefit from or if you're at one of these programs then shaking usually with maybe the transplant or the endocrinology, diabetes folks. Um um There might be programs that are available for your patients to use beyond your clinic, so I don't think we have any other questions here in the chat at the moment. Um So maybe we will just move, catch up a little bit of time here and move to our break, Uh and we will resume our next session at 10:30.
