Dr. Patel and the interventional cardiology team from Georgia Heart Institute present a live case of a patient with chronic total occlusion that required the use of antegrade techniques due to the complexity of the patient’s condition.
All right, folks. Um Hopefully, folks are gradually coming back and we're running a little bit behind schedule. Uh So we're gonna go ahead and get started as folks roll in. Uh My name is Hugo, I'm the section director for the heart failure uh department at GH I and wanna welcome you guys to our heart failure section discussion today. I know we've had a lot of discussions about interventional and all sorts of stuff. But I think for me as a heart failure cardiologist, I may be a little biased, but ultimately, everything leads to heart failure, right? So you can abate stent eventually, you may have heart failure and we've got to figure out a way to fix it hard having said that um our discussion today will start off with a very topical issue in the field of heart failure. Um Therapy has become better and has really good outcomes. And now we're, I think we're at a point where we have some as to what should be the first line therapy. Um Our first discussant is Doctor David Byron. Um he's a well known cardiologist and he's the section head of uh mechanical support and heart transplant at the Cleveland Clinic, uh in Florida. And we're gonna invite him to propose a point that L A is now in first line therapy for advanced heart failure. Doctor Baron. Uh, thank you all. I greatly appreciate, uh, the first test, I guess there's two, try. The one on the right. So, um, the section head for heart failure transplant at Cleveland West. Ok. Maybe the one on the left. No, both at the same time. Mhm. All right. Well, uh all right. Well, let me go back one uh disclosures. I've worked with a variety of the device companies. Uh None of that is particularly relevant to what we're going to talk about today. But a relevant disclosures that I must say that I love transplant. So uh defending the other side is a little interesting, but there's always a tough decisions to be made. And you can imagine the plight of our patients when you're so sick that you're considering either taking your heart out or adding a mechanical device for the rest of your life to support you. None of these are easy or made lightly. And I always tell patients if they uh come upon such a decision and like, yeah or whatever, then they really don't understand what we're talking about because these are all very major lifestyle interventions. And however, our task today is to really defend to you why ventricular system I should be considered really the primary the first line for eligible end stage heart failure patients. And when you're trying to decide between something good and something best and maybe something in between what's better. You really have to learn more about each of the things and what is the pre and the post for each of these interventions? And how long do they last? That seems pretty logical way of approaching this problem. Well, what do we have with evaluation for a pre for a VAD? The evaluation is fairly basic? You really just need to know the left heart is bad. Well, that's obvious. And you have to know that the right side which is not supported by the left ventricular cyst device is ok. And can the patient plug in the batteries? It's really a low bar. Can the patient actually take care of the thing? And then you can ask your surgeons, can they get in the chest? And it's really unusual that they can't with the power saw yesterday, saw the amazing robotics, maybe they don't even need the saw, but for VADs, probably still need to be able to open up the chest and then schedule the operating room. This seems like a pretty simple to do list either elective or semi urgent. And what are you in in a graphical format? You can see you need a patient who's sick. You wanna look and see if they have noncardiac conditions. Can they be anti coagulated? Because all the pumps today require anti coagulation? And are they actually able to walk up? Right. Are they at least adequate? And you probably wouldn't put a bed in somebody who is crippled by other things who was so direly ill that they weren't able to function. But that's pretty low bar. And what about under the hood? Well, we probably do a rear calf because we're cardiologists and we love to look under the hood. Uh, we'll do it echo because we can. And really the biggest thing is make sure they don't have lots of bleeding because you're gonna to thin their blood. Ok? And then it's go time so far. It seems pretty simple. Either it's inpatient or in fact, you can even go ahead and send them home. Have them come back at a scheduled date, a nice morning case for ventricular assist device. Uh Well, that's quite different. Ladies and gentlemen, than transplant transplants. Probably the diametric opposite of this. Well, first let the blood letting begin. We don't have leeches anymore, but we really do when you have transplant. If you've ever sent a patient for such an intervention, they check you for every disease you could ever imagine including diseases you didn't even know exist. And then you look for more things that are more obscure. Maybe chat GP T knows all the bloods. But when I send a patient to, they come back and tell me 40 tubes later, they wonder they're lucky that they survive the bloodletting. Well, what about that? After that? You have the wheel of consults. Well, you have consults, at least for every single organ and even for organs you don't normally think about. We need to check everything out. That's extremely laborious. Imagine the outpatient plight to the patient having to go through all that. And then they have to run the gauntlet of interviews. They have to hope that they don't say something wrong because somebody might say no, you're gonna die because oh you, you did this or that or whatever and who among us can get through these incredible interviews, psychs, social work, nutrition for pulmonary, cardiothoracic surgery, hematology, gi I renal palliative care in case maybe you really don't want to do this and you're probably going to die anyway. And maybe you should just give it all up. Oh my God. When you get through all of these things, what patients going to want to do this and if you do manage to get through all that, you end up with the really long wait. Why? Because, well, Doctor Lin may not share with you, but when you're home and you're stable, you may mate months or years, you have end stage disease that's gonna kill you. But don't worry, we'll call you eventually really. In fact, you usually need to be extremely ill till you finally get the gift of life. Well, in fact, you know, you tell the patient you're sick enough that you need a transplant. We're gonna rip your heart out and put another one in. You're not quite dead, you're not dead dead. You're only mostly dead. Really? And you're gonna sit home and wait or are you gonna choose the right option? Just go ahead and choose a ventricular assist device and come next Tuesday when your surgeon is fresh. Well, let me skip. Ok, you've already decided you've gotten the device, you've gotten the transplant, whatever it may be. What's life like after the, well, you have normal post surgical recovery. We were in there with the, you know, sternotomy. Saw, you have to learn how to take care of the drive line, you know, coming out of here. Ok. That's what keeps you alive. All right, biggie deal. And then you take your warfarin because it's your blood thinner. Someday. It props you'll even just take eloquent. But for now it's warfarin. You learn the batteries in the controller and you now go home and enjoy your life without heart failure. Sounds pretty good. Here's a visual people from all walks of life. You don't have to be the youngest, nor the oldest and it's pretty darn simple thing to do. Well, what about transplant first? Is the sledge hammer of immuno suppression which comes down before you even wake up off the ventilator. They immediately turn your body inside out. They suppress every t cell that knows how to function. If the patient then recovers from the ventilator, then you immediately assault them with classes every day to learn the immunosuppression regimen. They have to adapt to a life where they don't have an immune system much anymore. They constantly have to worry about rejection. And of course, the leather neck. And if you look at this from a vascular point of view, you see the sledge hammer in the top corner, the pill box and our patients can barely manage the difference between Entresto and SGLT two antagonist. But don't worry, we'll make it 10 times harder for them with all these meds. And if you skip one, you're dead, that's pretty easy. You patients always worried about rejection, they're bruised. You see in the bottom middle, my God, all in the name of trying to protect them, we're constantly going in their neck. Dracula never had it so good. And then you make them the boy in the bubble where? Well, that's fine. You've got this great gift, but really don't leave your house too often because you might get infected and you might die. Well, the evaluation of bad and transplant, you see, we've all evolved and you see to the person on the right. That's pretty physically fit. Well, trans fund has evolved too, began in 1967 when there was no G in the GDMT, there were no guidelines, there were no meds, it was a miracle. OK? We managed to do this, that poor man. He lived. Uh what nine days that that's pretty good. And in fact, in two, in 1973 it was even as often said today, the tragic record of heart transplantation. Sure, we've gotten better than we were. But this is a picture of uh six people, all of different walks of life, different genders, etcetera. They all share one thing in common. They're all dead within a year after the transplant. And he said, well, come on, Baron, you're being silly because we've gotten much better. Yeah, we've gotten better. This is a patient of mine when I was in Mount Lisa. Lisa waits for heart. This was about 15, 18 years ago. It's no different. The line is even longer today. It's longer than a Taylor Swift concert. So everybody's waiting. But how many are getting in? Uh and oh my God. Look at this complicated slide. A million ways to die. But don't worry, Doctor Linfield would say none of these things really happen except in the data does not lie. There's a million ways to die after a transplant. Oh my goodness. Uh And yes, if you look long term, sure. If you one of the lucky few, you might live 20 years, but you might not the evaluation of a mechanical heart. Sure. We started off with the Barney Clark Heart where you need a separate doctor to be just controlling the machine. But we now evolved to FDA proof, simple straightforward device. Look at the controller, look at the batteries. How much simpler can it get? And data? Well, 60% survival at five years and we're getting better and better. Eventually we won't even have that drive line anymore. That comes out of the chest. You plug in the batteries, you take your blood thinner and you move on with your life V versus transplant. Well, I think clearly that is on the left and I'm sorry, Dr Lend transplant much as I love it for the chosen rare few. We're still back in the days of the Wright Brothers. That is the way. Thank you. Uh Thank you doctor for that. Excellent enlightening uh discussion. Uh We're going to just open it up real quick if there's any questions that folks wanted to ask and then we'll subsequently switch over to Doctor Linden so she can give her a rebuttal any questions from the audience. All right. If not any comments uh from our panel, any comments, Roger, I know you were holding on to your seats when you heard some of those comments. Yeah, but before we talk about transplant versus that, you know, we have a positive of heart failure physicians. So what do you guys feel about? When's the right time to refer to get evaluated for vat or transplant, the sooner the better? I think the sooner the better. I mean, that's one of the challenges we face in our uh heart failure clinic. We end up getting uh these patients referred to us when it's, when they're too sick. You know, a lot of times, you know, with comorbidities that make them um ineligible for either elbow or a transplant. So I, I actually can't agree with you more. I would say that the one lesson if anybody in the audience takes away is that heart failure is cancer of the heart. If you have a melanoma, you want the appointment with the dermatologist the next day because you won't have. And yet I see people constantly 3rd, 4th, 5th admission before they're finally sent to the heart failure center. So heart failure, cardiac cancer, please send your patients early. You and doctor Barrett, could you talk more about the uh survival rates for post a patients especially, you know, that 2 to 5 year mark and how that compares to transplant? Thank you. So, um you know, so LVAD survival, we're all sort of colored by the early experience by devices that didn't work. Well, remember back to rematch where most patients didn't live past two years, but at least at one year, it looked a bit better with the V ad. That's old data today. Heart rate three and what may come in the future is quite, quite different. None of these are perfect and beds are certainly not perfect either. But you can expect if you put a ventricular cy device in, there will be patients who will live 10 or more years and at least more than half will live five years. And so you're taking a population of patients by definition that are very ill that are unlikely to live a year and you're giving them 5 to 7 or more times the survival. And it's moving target keeps getting better and better and better. And in particular, for me, the thing that ventricul lucy device allows you to choose when you want to intervene. Whereas in transplant, while we've done more transplants over the years than lately, the problem is you have increasingly sick patients who are almost dead before they get a transplant. That's not a viable long term plan. In my opinion, uh You spend a fair amount of your time at Duke uh taking care of his patients. What's your view on that therapy as first line option? Well, I, I sort of am curious to hear what Doctor Linfield says first because she will, she will probably take some hits at Doctor Baron. I feel bad about it. So, I mean, to be honest, can I hold my question to Linfield is done because I don't want to take away any point. All right. All right. Any other, any questions from the audience? Any comments? All right. So we'll go ahead and invite uh Doctor Joanne Lin uh to give her a rebuttal. Uh Her talk is gonna be entitled Heart transplantation is still first line therapy for advanced heart failure. Uh Doctor Joanne Linda is a full professor at Vanderbilt and she's the director for the advanced heart failure uh transplant program. And I think, you know, under her leadership, it's become the number one transplant vat program uh in the United States. So we'll be, we'll be happy to hear her comments on transplantation. Thanks. All right. Thank you, Hugo very much. And uh let me get going here because I thought this was 15 minutes. I do have some relationships with industry. So this really isn't quite fair, right? Really guys, this illustrious international cardiologist who goes to the Cleveland Clinic, I'm supposed to debate him who also has written a zillion papers about this. Right? But there's only one disadvantage for Doctor Burn and that is he's wrong. So two common advantages for LVAD that he discussed that are changing considerably. One is that L VDs have an advantage because we don't have to wait. Well, our wait time at Vanderbilt is six days. I mean, now, clearly, if you think you're going to wait a year, that's a different story. If you're waiting a year at your program, there's a problem. Um, and weightless mortality. So we talk about what is the risk of having your ad right now versus the one year weightless mortality right now. For whatever reason, the United States, it's 10% that's very close to the immediate operative mortality of. So I'm not sure that's an argument and then donors are extremely limited. Well, yes, they are. I can remember a few years ago, when we thought that 3200 would be the maximum number of transplants in the United States. Last year, we did 40/4100 this year, we're targeted right now to do 4500. Why is that changing? Well, for two reasons here, you may have just seen in the New England journal that we're now taking donors who aren't just brain dead, but who have cardiac death and then can be used for transplant. And this paper was a randomized study in which we participated using the heart in the box. But we also have in press a paper using a different type of perfusion for these cardiac dead donors that's equally successful. So this is a large number of donors. And then earlier on, we showed that you can use hearts from hepatitis C. Positive donors treat the hepatitis C and have an excellent outcome. So donors are increasing. So we'll just be done with those arguments. OK? There you go. So, and also what I'm gonna do today is as Dr Barron rightly pointed out the HeartMate three is the class Velvets. That's pretty much all we do this nonpulsatile LV. And so everything I try to do, I'm gonna try to compare with the very best LVD data that we have. And here's what I'm going to compare, right? These are the things that are important, long term mortality, rehospitalization, serious adverse events, exercise capacity and quality of life. So let's just go through those one by one. So here's the slide that he showed you about el this is the very best we have the heart made three and the mortality at five years. I hope you can see this uh is, uh, let's see, that's a 24 1. So 78%. But what you'll see at five years is, it's, it's 60%. This is death free from disabling stroke. So that's not death. But I think most of us would consider it a pretty close death and disabling stroke is pretty close to death. What is transplant? All right. Well, here we see. I, I've shown you here in the blue, the one that's closest to the age of ads for transplant. So I'm not taking the youngest or the oldest, but the age that's closest to the LVAD data that Doctor brand and I have both shown you. We see the one year mortality, one year survival is 92%. 2 years. Here is 86% 4 years, 78% and five years. 75%. 5 years, 75% for transplant. What was that compared to the data that we've both shown you with the very best device we have 60%. OK? You choose 78 or 60. All right. So there we go. Long term mortality, transplantt column rehospitalization. Here's the freedom from hospitalization for vs the nationwide data. This isn't very much better. Maybe just a touch but not very much better with the heart made three. So you can see a 12 year, 80% of people, 20% of people are free of a heart failure of a hospitalization of some sort. For, what is it with transplant? Well, here's the international society all ages but way better, right? Way better. So I would ask you on rehospitalization. Are you gonna go transplant or L A? Right? 20% free of hospitalization, about 60% free of hospitalization in one year. Seems like a pretty clear choice to me. All right. What about serious adverse events? So here I just listed, I I'm not gonna show you all the references but the there's data for all these. What are the most common causes of readmissions for both in the first year for L A. It's bleeding infections from the drive line but sometimes systemic infection, cardiac, both arrhythmias and heart failure and stroke. With the very best data, we have the risk of stroke with an L AD with our heart rate. Three is 5% a year. Every year. You have it every year you have it. That's 25% risk of stroke at five years. That's the best data we have it used to be 8%. All right. What are, what are the serious adverse events with transplant rejections and graft dysfunction? That's serious infections, sometimes serious, sometimes CMV and stuff procedure related complications. Yes. And acute kid kidney injury, which is usually resolvable. So, all of these LVAT complications are almost always chronic bleeding, chronic drive light infections. Once you get them chronic right side and heart failure stroke, these are chronic. What about these transplant? Adverse events? Oops, sorry, those are usually resolvable. So I ask you now, I think I've shown you pretty clear data wide separation, mortality, transplant, rehospitalization, transplant, serious adverse events, transplant. Do you want to come in for steroids or do you want to have a stroke? Ok. No, I'm just making the point, right. This is pretty easy. All right. Well, let's say, OK, maybe it's not everything, you know, maybe with those LVAD, they're pretty powerful, there's better exercise capacity. So here I just summarized on the left hand side, these are older data, but the world exercise on the bottom there. The journal of transplant, what's the average vo two after transplant from an, a range of 50 to 59? And it's about 17 millis of oxygen per kilogram per minute. It is not normal but pretty good. What is it for LVAD? It's 11. This is Donna Mancini's recent paper. That was almost all heart rate threes. It's 11. All right. I ask you 17, which is not even in the range where you'd be transplanted or 11 where every day you need to be rushed to transplant, right? All right. But maybe quality of life is better with an ELD, right? You got this big thing sticking out your side and it gets infected all the time, but maybe it's better. What is it? Well, with transplant, I've just enlarged these data for you. LVAD improves the quality of life. So we can use a disease specific quality of life, which is the KCCQ, which we have to watch out for. Because disease specific for heart failure means it mostly assess the shortness of breath. So you could see with an ad that you could make shortness of breath a lot better, but you might be visible miserable from a drive line infection. So it depends on what the questions ask. But on the bottom, there is a non disease specific, a general quality of life. So for transplant, it's 70% for a disease specific quality of life, 32% improvement for a non disease specific for that. It's 40 15. OK. 70 40 32 15, you choose. That's all right. So hopefully by showing you the data with the very best options we have for LVAD right now, irrespective of immunosuppression, et cetera, transplantt wins for long term mortality, rehospitalization, serious adverse events, exercise capacity and quality of life. And it's not really that close, right? So are we there for L ads? I would concede that L ads are much better in today's world than they used to be. And we are almost, I think there we have a few things to do, like getting it to be totally internalized or getting long term batteries where you don't have to lug these things around. That may be a ways away, but it is almost there. But I just want to show you why, almost, why almost is not always that great. Ok. At the risk, I know I'm in the south because I've lived here in the south for eight years at the risk of being risque. Some of you may remember Jack Lalane, right? He was this famous fitness group guru when I was growing up. And this was his picture on the front of night and he used to swim across, I don't know, all sorts of horrible channels and things and survive it. And he turned 93. He was on the cover of Time magazine. This was in 2007 and he said, I'm feeling great. I have sex almost every day. Of course, you have to read the bottom part of the article when it says almost on Monday, almost on Tuesday and almost on Wednesday. So I think I've made my point. Thank you very much. All right. That was a very lively discussion there. Um So I'll throw it out quickly to the audience. Any questions that anyone has. Um If not, I'm gonna go back to our panel. Oh, someone has a question here while we're getting through, I'll ask the panel question. So now we have the data we've kind of looked at transplant versus vat. Um We'll go back to your, what is your overall gestalt? Well, I think, uh you know, the data speaks for itself in the new transplant guidelines released, you know, five plus years ago, uh we had an upsurge of uh transplants due to the way we transplant, due to the way uh way we allocate transplants at our center, which is with Vanderbilt right up there on top, for the numbers we do preferably go for transplant. And I think that reflected most centers where with the equal amount of transplant and VADs and now most centers do more transplant than vas if both are available at the center. So I think it is, I agree with doctor. It is the preferred strategy. If, if you pass through the committees and the tribunals, it is the preferred strategy. But if not, then the LV tends to become a Plan B but it is usually considered to be Plan B at our institution. All right, I think we have a question. Well, we were talking and it was our understanding that A ad is a bridge to the transplant. So why are we talking either or doctor? So that's a, that's an awesome, awesome question. So one of the interesting and unfortunate parts of the 2018 change in allocation is you're exactly right. You used to have somebody came in sick, dying awful. You put a ad in. Then a year later you transplanted a walking talking person with a good donor. Choice. That was the previous. Now, what happens is patients who are stable on a VAD or status for? So basically, it's the, the back room, the, the Dollar Store that nobody wants when it's reduced to 50 cents. The donors for the outpatient stable ad are few and far between in most centers. So it really is uh a completely different uh status these days and maybe the six day waiting time. I, I correct me if I'm wrong, Doctor Linfield, but those patients who wait, six days are almost dead on the seventh day, so they get transplanted. Um And I know there may be a lot of donors with Doctor Shaw and the others, but you're not transplanting in six days, the person who's sitting at home waiting because we have lots of those patients. Um But that's not she or I that's the allocation the way it was done. In fact, if you look, we have a recent paper in LT, it's the same thing that's happened in Europe in Europe, for example, in Germany patients get a ventricular cys of ice and bridge. The transplant is very rare because there's always somebody sicker more ill. And so it is in fact, two separate tracks these days in the United States, you get a ad unless your blood type may be and you, you bought a building or something, it's unlikely to uh to actually get a transplant anytime soon. Well, certainly there are subsets of patients who, you know, like say someone is 74 years old and they're not a candidate for transplant, they can have a bad place and that's their only therapeutic options. So, really a discussion we're having is the patients that could potentially go one way or the other, right? Um One of the questions I wanted to ask, um Joanne and, and Dave as well, you know, now that we know about specific subgroups of cardiomyopathy. So for example, you have a 30 year old female who has prepartum cardiomyopathy and clearly has state uh evidence of instant heart failure. Um Is there a strategy or a role for a bad first process for a younger patient? Allow for potential recovery, potential explant versus do you commit them to a transplant? Knowing? I think on average maybe 10 years, you imagine a 30 year old goes to 40 by the time they're 40 you may need to look at the retransplant or some other process. So, could we potentially look at these therapeutic options and have different strategies for different patients? So perhaps there's some patients that are bad for a strategy and then there's some subset of patients who are transplant, I guess I can start with that. So I think, you know, we did this as a debate and this is an individual decision based on the debate. I think all of these things and one reason it takes time I would say in our institution and I would guess in everybody's that the evaluation for L that is almost exactly the same as it is for transplantt. I, I don't think it's very different. So I think that that process takes a while but um and they have to have caregivers equally and that kind of thing. But um this is very individual. So what I would say is if you have a young woman with peripartum cardiom who presents and is so ill that you think she's gonna die, but you think there's a chance of recover ability, then we would certainly think about putting in an LVAD um and trying to recover that heart and see if they get better and then explant the vet as opposed to going straight to transplant. If a transplant were available. On the other hand, if it's a 33 year old woman who's had chronic peripartum cardiomyopathy progressively over three or four years, and the ventricle has dilated that person's not gonna recover. And then if you have the time you would go to transplant, I think. So, I think it's, it's all of this is much more individual and I think a debate would make it out to be. Yeah. And, and you know, the, the simple fact of this is if you look at uh you know, does the most vat vat in the, in the, in the world and we explant far less than 5%. So the, the, the hope and promise of an explant and recovery on a VAD despite aggressive medication therapy and all that stuff is very uncommon. Can I just one other thing when we started transplanting several years ago, Hepatitis C donor hearts before it was standard and we had a permission form we took to all the patients and we said this is a, you know, this is a registry that is a research registry. We think this is feasible. You can potentially get a heart with the Hepatitis C donor and 99% curate. Um or you can go to an LVAD and wait for your transplant on an EL VD. It was the most overwhelming response from every single patient that they would take the Hepati. We were stunned, all of us were stunned that they would take the Hepatitis C heart, get the transplant, get cured rather than they have to go through two major operations. So, um you know, I think that's, that's a little bit something to think about too is that the patients, if they can avoid it, don't want to have to have two major operations. So I think you and I agree with Doctor Linnel, you know, it's interesting and so of course, you know, we we both take care of patients, both VAD and transplanted. The debate is, you know, makes a binary outcome out of something that's very individualized. That being said, I agree with doctor doctor. Doctor said that, you know, a recovery, it sounds good, you say, well, it's a young person and we'll give them 10 or 12 years on a ad. And I indeed do have some patients who are 10 or 12 years out, but they're the exception. Um In addition, you have to factor in the way the patient and family looks at things. Um, you know, a heart transplant has the idea that it's a cure. And I always tell every patient if a heart transplant, I said, you know, this is not a cure. This is treating a disease that will kill you for a disease that's very, very slow. And the disease in the sense that patient that gets a transplant doesn't take their meds. They're, they're dead. Patient has a ad that doesn't take care of the drive lung will die awful drive line infection or right heart failure or they'll have a stroke. So, none of these are curative. But if you ask the patient in general, Doctor Linden described that overwhelmingly, people said, give me a heart because it's the idea that, oh, it just solves all the problems and it certainly does solve the problem with the right side of the heart, which current el beds don't treat. But if your question is today, I see a patient who's 30 they say, well, am I going to buy you 10 years? That's assuming that they're lucky that 10 years later, they're a good transplant candidate. And 10 years later, when you decide, OK, the heart didn't recover, then how are they going to get a transplant? Because the priority allocation here and in other parts of the world is they're stable on a vat. Even if they're miserable with the driveline infection still, they're not likely to get done. So a lot of times that calculus at the table as well, persons crashing, burning, maybe they got to go on ECMO or something. I can cool them off and put a ad in and then I lose my chance to transplant them or go ahead and transplant them? Um very complex. So can I just make just one quick comment because this is an incredible uh discussion. And I love the fact that it was pitched as a debate. And I think you both made the case that the debate was there just to kind of air out the opposite sides. But I do think for our audience, it might be useful for one of you to kind of zoom out as I think you did in the uh EMT conference that we had and just talk about what's the denominator of patients with advanced heart failure and of that denominator, you know, whether it's 4200 or 4500, what's the opportunity with transplant? What's the opportunity for vat? So people can have a kind of a zoomed out view of this discussion if you could take any one of you take a minute or two and just describe that. Sure. Yeah. So this this is talking about stage D heart failure. So out of approximately 5 to 8 million patients with heart failure, you're talking about 30 to 50,000 patients roughly with stage D heart failure. So you know the number one treatment for heart failure is prevention in medical therapy. We don't, your heart is the best heart. So we want medicines and we want to prevent this disease from ever happening. So it goes on the medicine level, population health level internist, everybody out there to educate your families and educate the society that as doctor Baron said, heart failure is cancer. So we need to have as much importance as we do with cancer, with heart failure and then of the 50,000 with advanced heart failure. Now we're talking about L ads and transplants, put those numbers into context. So as Doctor Linfield said, there's about 4000 rough roughly transplants and how about how many roughly VADs are done? Only a few 1000. But that's a separate issue because they're available. The company will make as many as you want. I I would say the problem is that they don't get referred and if your center starts doing bads, you'll find all sorts of patients that otherwise were dying in the community that you may be able to save by bringing the therapy to them locally. Correct. And certainly that's what we found up since we started our program there. That early outreach and really building that connection with the community is very important. All right. Well, that, that was a really good, lively discussion.
