Sitaramesh Emani, M.D., Director of Heart Failure Clinical Research at The Ohio State University Wexner Medical Center in Columbus, Ohio, talks about a new treatment for patients who suffer from heart failure.
Interview conducted by Ivanhoe Broadcast News in April 2017.
I want to start by asking you, when our viewer’s hear the term “congestive heart failure,” could you tell me what this is?
Dr. Emani: Heart failure is a disease process that can come from many causes, but at the end it is something that affects the heart, such that it cannot pump enough of blood and energy to the rest of the body. As a consequence, there is often a build-up of excess fluid into the lungs, into the stomach, into the legs, which contributes to patients feeling short of breath, tired, or a very common symptom, which is to be swollen.
You said it is caused by a number of things, can you run through a few things that can cause this?
Dr. Emani: The most common cause in the United States for heart failure is a history of coronary artery disease, more commonly known as “heart disease” or “blockages.” Patients who have had heart attacks in the past, bypass surgery or stents are at risk for developing heart failure. Other causes included a long-standing history of high blood pressure and certain genetic causes.
And if heart failure is untreated, what happens?
Dr. Emani: Untreated heart failure leads to patients feeling progressively more and more tired, short of breath with activity, ultimately short of breath at rest, wrestling in bed, unable to sleep, unable to lay flat, and uncomfortable because of weight gain due to fluid building up in other parts of their body. Unfortunately,it is a fatal condition.
What are some of the treatments?
Dr. Emani: The main treatments are to help remove the excess fluid using what are commonly known as water pills, or diuretics. Then there are specific medications that we use to help make the heart stronger and more efficient to allow blood flow to get to the rest of the body. Patients who need more than that can often get specialized devices like pacemakers and defibrillators. In our advance cases we can use mechanical heart pumps, or for a select few patients, a heart transplant is an option.
At what point is a transplant is your only option?
Dr. Emani: We consider that as a truly last option for patients who continue to have problems with heart failure despite all of the other best therapies we have. When our best medicines, pacemakers, and other associated therapies do not work, and patients continue to end up in the hospital, or feel extremely tired and fatigue because of the weakness in their heart, we consider them for a transplant.
Tell me a little bit about this new therapy, this new procedure that you have used?
Dr. Emani: For vast majority of the patients that come into the hospital due to their heart failure, the main symptom with which they present is excess fluid being built up in different parts of their body. When the body holds on to extra fluid, it tries to get rid of it through the kidneys. The challenge is that blood flow doesn’t get to the kidneys well, because the heart is weak to start with. This causes a back up. I often use an analogy of the drain in your kitchen sink. If the drain backs up, fluid backs up into the sink the same way it backs up into part of your body. When the body has to move fluid internally, it has got a couple of different pathways that to do that. One of the pathways is something we call the lymphatic system, a series of small vessels that help move the extra fluid from legs, stomach and other places back towards the heart, so the heart can then pump it to the rest of the body. This particular procedure is aimed to improve blood flow through the lymphatic system; in severe heart failure we know that lymphatic system does not drain blood and does not drain fluid as well as it could, so we are aiming to increase the flow of fluid back to the heart so we can then use the water pills, or diuretics, to help the body to get rid of it in a more efficient fashion than we would otherwise be able to.
Can you describe for me, step by step, how the procedure works?
Dr. Emani: In order to perform the procedure we have to find a large vein into which we could put the catheter. We prefer the left internal jugular vein, because it sits very close to main lymphatic vessel, the thoracic duct. We bring a patient into the cath lab, and using x-ray and ultrasound guidance, we identify where the vein is. We then put a small needle into the vein through which we put a couple of wires and then put the catheter over the wire into the deep vein. The tip of the catheter sits inside the chest at the location of the thoracic duct.
And what happens from there?
Dr. Emani: Once the catheter is in place and secured, the patient is returned to their room. The catheter is designed in a special way that it is hooked to a console that allows blood flow to be taken out of the body and then circulated back into the body. The specialized design of the catheter does this in a way that actually targets the flow coming out of the thoracic duct; flow is stimulated directly from the thoracic duct by the catheter.
What else is happening?
Dr. Emani: While the patient is connected to the console and blood is circulating, it actually drops the blood pressure in a very particular vessel and a particular area of that vessel to allow more efficient flow. At the same time, we continue to give the patient the appropriate medications for their heart failure to help them and help their kidneys filter the fluid out of their body.
How long does the patient need to be hooked up to the system?
Dr. Emani: The system is designed to run up to 72 hours. We are continuously monitoring the patient to know when the best time to stop or continue the treatment is. We check blood work, vital signs and we measure how much extra fluid they have in order to know; and in our patient’s case we ran the console for 12 hours, which to date is the longest run in the world. The average has been six hours previously.
Is there any indication how much fluid his body was able to release as a result of this? Was it almost immediate help for congestive heart failure, or was it progressive?
Dr. Emani: It was very quick to help. We saw improvements within the first thirty minutes and ongoing improvement through the 12 hour period. The catheter is designed to actually measure internally what we are doing and that is the number we followed to see what the pressure and extra fluid amount was.
By improvement, you saw the pressure lower and more fluid being released?
Dr. Emani: Correct, we saw the pressure that collates to the amount of the extra fluid start to decrease.
And what made Mr. Rozelle a good candidate for this?
Dr. Emani: Mr. Rozelle was a great candidate because he had all the classic findings of a patient coming in with heart failure. He was short of breath, his weight had gone up because of extra fluid, on exam you could tell his body was holding on to a lot of extra fluid and clearly he needed something to help him feel better.
Is there anyone, for whom this would not be a good idea, they would not be a good candidate?
Dr. Emani: It is not a treatment that we would use for everybody. Patients have to be willing to and able to undergo a procedure, and have a catheter in them for up to three days. Specifically, we use blood thinners during the procedure so there are some risks for a procedure like this. For patients where we feel the risks are too high, we would not want to do this because we wouldn’t want to harm them.
Can you tell me a little bit about Mr. Rozelle and his case, how much better does he look?
Dr. Emani: Mr. Rozelle looks great now, in fact, by the time we finished the treatment, the day he went home from the hospital he was feeling much better than when he came into the hospital. He was walking around the hallways here, he was laughing and joking. Before, when he first came in, he had a hard time talking, let alone cracking jokes with us. He has responded the way we would like and continues to do well, which is the other goal of the treatment in the hospital. Not only to make you feel good while you are here, but to have sustained benefit and hopefully to keep you from having to come back to the hospital in the future.
What are the implications for having a procedure like this, what does this do in terms of treatment options?
Dr. Emani: We know that one of the biggest challenges with heart failure is making sure we get enough fluid out of the body safely. This particular procedure has the hopes of allowing us to take out more fluid in a way that is safe for the body, safe for the kidneys and blood pressure. The more fluid that we can take off, the better we can use other treatments and medicines to continue to help with heart failure and the better the patient is when they leave the hospital.
You are the first in the country to have done this procedure?
Dr. Emani: Correct.
Okay but not the first in the world. It’s done in Europe?
Dr. Emani: In Israel.
Is there anything that I didn’t ask you that you would want people to know about this procedure or about your patient?
Dr. Emani: It is part of the clinical trials so that we can better understand how to improve therapies. We hope to use information from this case combined with future patients, to which we would place a catheter, to really understand how to treat the larger population of heart failure. We are extremely grateful to Mr. Rozelle for volunteering to be a part of this trial, and we are extremely fortunate to be a part of a large research team, all of whom played critical roles in helping indentify the patients, take care of the patients, and monitor the patients. It is a team effort centered on the patient; all of the effort is to make treatments better for him and future heart failure patients.
He still has follow-up appointments and he is still on cardiac rehab is he not?
Dr. Emani: Correct, part of the treatment for heart failure once you leave the hospital is to continued to follow up in the office, so we can adjust medications but also to do other things to help a person’s strength and general energy levels improve, such as cardiac rehab.
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.
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