Advanced Heart Failure Cardiologist at Allegheny Health Network, Matthew Lander, MD, talks about healing hearts with a new device.
Interview conducted by Ivanhoe Broadcast News in 2023.
Heart failure is almost an epidemic in this country. Can you just talk about exactly what this is and what is happening in the United States, in terms of heart failure?
Lander: Sure. So in general heart failure is one of the most common diseases that patients come into the hospital with, leads to a lot of health care costs, a lot of morbidity, and unfortunately, mortality. And really about probably 50% of patients that have heart failure are going to pass away from heart failure within five years. So actually is a disease that people are probably familiar with, people have heard of people that have it or maybe know or have a loved one that have heart failure. Really 6.5 million people in the country that have heart failure of some type. And it has a devastating toll on a lot of people in this country.
What are the main causes?
Lander: So I think in general, most of heart failure can be divided up into either ischemic or related to some coronary artery disease blockage or previous heart attack, and then the rest, which we can term non-ischemic cardiomyopathy. Similarly, about half of heart failure can either be because the squeeze of the heart is weak. But also half of heart failure can really be when the squeeze of the heart, the movement of the heart is normal, but the heart just doesn’t relax normally. And that can be due to a lot of factors. As we all age, we are a little bit more at risk for that. And so knowing what type of heart failure can really lead to understanding how we can best treat it.
And having heart failure, how does that impact patients? What does that look like for them?
Lander: And so as I mentioned before, it has a huge toll on patients in terms of just the mortality that I mentioned earlier and such a high burden of in and out of the hospital, symptoms, limitations at home doing the things that we all want to do, keeping people and really loved ones too, that have to support their partner, spouse, relative through these really challenging trips to the doctor, trips to the hospital, long time in the hospital, maybe time in a rehab center after the hospital. So as you can imagine, the economic toll too in the millions to billions of dollars just in terms of this one disease.
And when you say symptoms, what symptoms?
Lander: So really the symptoms that patients are mostly going to have is shortness of breath. And so really when they try to do, maybe it starts innocently enough, they can’t walk up the hill with the dog the way they used to. But maybe it starts to become, they can’t carry the laundry basket upstairs. And then maybe it’s to the point where they’re short of breath at rest or they wake up at night because they can’t breathe properly. Of course, some patients can have chest discomfort from this. They can feel, maybe lightheaded or dizzy in the activities they otherwise would typically have been able to do before. And so these are some of the things that we’re looking for. And then when we see the patient in the clinic we’re looking for, is there swelling of the legs edema? Are they building up fluid in their body because of the heart failure? Do they have fluid in the lungs? And when we listen to their lungs on exam and some other findings that we’re looking at to say, yeah this person is really suffering from heart failure.
How is heart failure treated?
Lander: So the thing that we look out for, again the most in the clinic or in the hospital, is this abnormal fluid build up. And so certainly the base of all treatment is oftentimes getting that fluid off and giving them a medication called a diuretic. So they can really just urinate off the extra fluid. However, that doesn’t really alter the course of their heart failure. It might make them feel better, but we have to understand why. And so sometimes if it’s related to an ischemic disease or coronary blockage, maybe they need heart cap done and find out that they have those blockages and fix those. But at the end of the day, really we’re using medications, several different classes of medications that truly can improve a patient’s symptom burden, can improve their likelihood of death and keep them out of the hospital. There’s four main classes of medications that we use. But just in general, these are things that are driven by guidelines from our major societies in cardiology and are extremely important that these patients, if they are a candidate, be on these medications.
Now you’re involved in a new clinical trial. What is the clinical trial?
Lander: So there is a device called the core cinch device. And so this is a device that is of great interest to us. To take a step back and talk about what happens if someone takes those medications I mentioned and they don’t do well or maybe they continue to have symptoms, then what does that look like for someone who maybe hasn’t reached the point that I and my partner sometimes see, which is someone that actually might need a heart transplant or a permanent heart pump. We reserve those for the sickest of the sick, and not everyone is going to be a candidate for those. So what is that gap in between medication meeting the end of its usefulness, so a really not having improvement or transplant. And I think this is the type of device that has an opportunity to bridge that gap. What this device is, is it’s a catheter-based device that’s released into the left side of the heart. And this is reserved for patients that really have a lower squeeze of the heart that I mentioned before, but also have some degree of dilation of the heart. As patients move on with heart failure, a lot of times the heart gets bigger and medications and other therapies have been shown to improve the size of the heart, which we relate to improvements in quality of life and to prognosis. And so the theory behind this trial, which is really still in a clinical trial phase of which we are a site here at Allegheny General, is that by improving the size of the heart, then perhaps we can have some improvement in other markers. And so this device is actually implanted and is using some catheter-based tools, is deployed into the heart. And as the name implies, that cinches the heart and brings the heart a bit closer together. And so by doing that, the idea is that the tension and the wall stress in the heart is reduced and that this can lead to improvement in symptoms.
How does the AccuCinch ventriliocal restoration system work? Is there anything else you wanted to expound from that?
Lander: So what we’ve seen in conjunction with our interventional cardiologists, the proceduralists that do this, is that it’s a procedure, perhaps a half hour to hour in length in the cardiac catheterization lab through the leg. And they’re monitored throughout this implantation. They also use echo guidance down the esophagus to watch the deployment of this device, make sure that it’s deployed in the manner in which it should be, and felt to be a relatively safe device to put in based on previous trials.
Can you just talk a little bit more about how reducing the size of the heart helps its function?
Lander: Yes, the trial itself, of course, is designed to try to answer that question. So what I will say is that from the previous trials that have come before with using this device, the again, hypothesis, and this is the whole reason we do the science is to- is that reducing the size of the heart, again, can reduce wall stress, and can potentially improve the likelihood of these heart failure symptoms, again, driving patients just to really to suffer. To go in and out of the hospital, and potentially even to pass away.
Can you talk to us about who would be a good candidate for this, and who might not be a good candidate for this?
Lander: So certainly there is a sweet spot where this device, and certainly for its current clinical trial, there’s always going to be a long list of inclusion criteria and exclusion criteria. For us right now, we’re looking at those patients that do have, again, that reduced squeeze of the heart where it’s just not pumping the way it should. And it has to be big enough to allow for the deployment of the device. There are other forms of heart failure, perhaps where someone has infiltration of the heart muscle from some other process like amyloidosis. Maybe someone has something like sarcoidosis, where there’s an inflammatory process going on. Maybe the heart is just stiff from something else, like thickened heart muscle from hypertrophic cardimopathy. Those patients are not going to be a candidate for this device. On the flip side, and then just clinically, some people maybe haven’t progressed to the point where they’re just too sick, and maybe they need something more advanced like a heart transplant or a permanent heart pump.
What are the risks associated with active usage?
Lander: So again, from previous data, the numbers would suggest that it’s a safe device to deploy. And we have to compare this to previous surgical efforts to reduce the size of a heart that have been published in the past. And of course we always feel that a catheter based procedure is, in general, likely going to have less morbidity and risk, than a big open heart surgery. Of course any time that we’re going into the vessels of the body, we can have bleeding, bruising, things like that, injury to vessels. Of course whenever we’re passing these catheters that deploy these devices, we have to be mindful of not injuring valves and injuring other vessels that go into and come out of the heart. And that’s why we’re also using the cath lab, with its capabilities with x-ray, and also using simultaneous echo down the esophagus, which we will call transsphageal echocardiogram, meaning that we can watch the deployment of this device in real time. And that’s how a lot of our typical catheter based valve procedures are also done. So try to reduce that risk of any intracardiac injury, catheters or wires going to places that we don’t want them to go.
From your personal medical standpoint, what do you like most about this procedure?
Lander: Well, I think that for us, when I see these patients in clinic and I have the luck to work in a great- with a great team, it’s a nice opportunity for us to really pool our knowledge, our skills, our resources to deliver a great experience and outcome to the patients. So we have- me and my partners in the heart failure group, we have the interventional cardiologists, we have our imaging cardiologists. And we can all come together and use a device that is minimally invasive, is non surgical, can go home potentially the same day, and have a therapy to really address that gap. We know that thousands, if not millions, of patients can respond to medical therapy that is appropriate. However many patients will progress with their symptoms, but they’re not yet to the point where we have to think about something so drastic as a heart transplant. And there’s potentially millions of patients still in that gap that need something. And this is something that can really fill that gap for some patients.
Are there any positive patient outcomes that you’re able share?
Lander: Right now, it’s really still in clinical trial. And we’re pleased to be a site for that- for that trial ongoing with really sites across the country. And so we are anxious to continue to enroll patients here, and contribute to what we hope will be positive results.
Is there anything else you wanted to add that we didn’t ask you at all?
Lander: I think for patients out there that are struggling with heart failure, or have a loved one that is struggling with heart failure, I think that it sometimes is a challenge to feel like you’re being hurt. Sometimes you’re given medications, and maybe they’re not at the doses they need to be. Maybe you’re not responding, and maybe you feel like your voice isn’t being heard. And I would just say there’s opportunities out there for clinical trial participation. And honestly, if you feel like you’re still symptomatic and you’re not getting over the hump, you’re in and out of the hospital, you’re not feeling the way you should, then you have a right to feel better. And I think that you should always pursue a second opinion. If you feel like you’re not getting the answers you need, ask your cardiologist or your primary care doctor to refer you to an advanced heart failure specialist, and we can try to see if there’s any way that we can make you feel better.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
If you would like more information, please contact:
Sarafina Brooks James
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