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Heart Replacement (transcript)
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(SPEAKER) 

Major funding for Second Opinion is provided by the Blue Cross and Blue Shield Association.  An association of independent locally operated and community based Blue Cross and Blue Shield plans supporting solutions that make quality affordable healthcare available to all Americans. 

(PETER SALGO)     

Welcome to Second Opinion.  Each week here you get to see firsthand how some of the country’s leading healthcare professionals tackle health issues that are important to you.  And each week our studio guests are put on the spot with medical cases based on real life experiences.  By the end of the program, you’re going to learn the outcome of this week’s case.  You’ll be better able to take charge of your own healthcare.  And I am your host, Dr. Peter Salgo.  Today our panel includes our Second Opinion primary care physician, Dr. Lisa Harris from the University of Rochester Medical Center, jazz musician, cardiac patient, Dr. Paul Smoker, Dr. Samuel Sears from East Carolina University, clinical nurse specialist from Thomas Jefferson University Hospital, Catherine Farnan, and Dr. Todd Massey from the University of Rochester Medical Center.  Our patient today is Craig.  He’s in his primary care doctor’s office where he goes pretty regularly, Lisa.  He’s forty-six.  He’s got high blood pressure, high cholesterol, and he’s obese.  He’s in his primary care physician’s office today because his legs, his ankles, and his feet are swollen.  He’s also complaining of feeling fatigued.  And within the past few days, he’s been feeling as if he can’t catch his breath.  What do you want to do?

(LISA HARRIS)         

You always worry about a patient like that, who comes in with hypertension and then starts showing signs and symptoms of having shortness of breath or what we call exertional dyspnea or difficulty breathing with exercise or even at rest.  So you want to start trying to categorize things.  And you’re wondering what his sodium intake has been like.  How long he’s been short of breath, what kind of activities, how far can he walk.  And then get a better sense of what is his blood pressure at that particular time, what medications is he on, and then do an exam to see if there’s any evidence of heart failure.

(PETER SALGO)     

Well, the chart isn’t all that specific here.  It does say that he’s been feeling fatigued for a few days.  And it’s been a few days that he has a feeling that as if he can’t catch his breath.

(LISA HARRIS)         

Right. 

(PETER SALGO)     

On physical exam, if you like to know this, since you did ask for his blood pressure, it’s 150/50.  And he is baseline hypertensive, so this is probably low for him.

(LISA HARRIS)         

Right.

(PETER SALGO)     

His heart rate is 110, respiratory rate is 26.  His doctor hooks him up to a little oxygen saturation machine on room air in the office.  It’s eighty-six percent.

(LISA HARRIS)         

He’s going to the hospital.

(PETER SALGO)     

He’s low.

(LISA HARRIS)         

Yeah.

(PETER SALGO)     

The doctor does take a moment and listen to his heart.  He’s got an extra heart sound, an S three.  And it sounds like this for those of you who would like to know.  I’m good at this, lubdupa, lubdupa, lubdupa.  How am I doing?

(LISA HARRIS)         

Pretty good.

(PETER SALGO)     

I like that.  He has crackles in his lungs.  His doctor finds pitting edema, which is his skin is squishy all the way up to his knees.  His back is squishy as well.  And his neck veins are bulging, even when he’s sitting bolt upright, all the way up to angle of his jaw.  What do you want to do?

(LISA HARRIS)         

Well, he needs to go immediately to the hospital.  This is someone who is apparently in biventricular failure, so it looks like both of the main pumping chambers of the heart have failed.  And he’s critical, because his oxygen content is very low.  And he’s had a fairly short onset of swelling.  So everything is backing up.  The whole system is backing up.  Backing up to the lungs, backing up to the rest of his body, so we’ve got to get them into the hospital.

(PETER SALGO)     

The next thing his doctor reached for was the phone, dialed 911, got an ambulance, took him to the ER.  Paul, what do you think Craig is thinking right now?  Here he is ambulance is coming, he’s still short of breath.

(Paul Smoker)          

Well, he’s probably thinking that he might die within the next few hours.  That’s some pretty serious stuff.

(PETER SALGO)     

You knew this because?

(Paul Smoker)          

Because it happened to me.  I had a heart attack.  And I didn’t have any of those symptoms until after my heart attack.  And they came on gradually over the course of about eight years.  But at the end, those were exactly what I was feeling, those symptoms.

(PETER SALGO)     

All right, now, Todd, I know you’re a surgeon, but now you’re a cardiologist.  What do you do when you meet him in the emergency room?

(TODD MASSEY)    

Rule out a heart attack.  Take a look at a chest x-ray.  You know, see the pulmonary edema.  See whether he has cardiomegaly.

(PETER SALGO)     

Pulmonary edema is water in his lungs.  Cardiomegaly means his heart is really big.

(TODD MASSEY)    

Yes.

(PETER SALGO)     

Floppy.

(TODD MASSEY)    

Yes.  I think that can give you an indication of whether—of how chronic this has been, whether it’s been chronic or acute.

(LISA HARRIS)         

See, we don’t know if he’s had a heart attack.

(PETER SALGO)     

We don’t know anything yet.

(LISA HARRIS)         

So, you know, if this was someone like Paul, who had had a heart attack in the past, then you’d be considering is this someone who now has a failure of the heart muscle because of damage previously.

(TODD MASSEY)    

Absolutely.

(PETER SALGO)     

He got the full cardiac workup.  He got the x-ray.  It looked like there was a lot of fluid on his chest x-ray.  And I’m going to summarize it all.  After a lot of workup in addition to the hospital.  He’s told that he has cardiomyopathy.  And specifically he’s told, Lisa, that you were right, his left ventricle, the left systemic pumping side of his heart isn’t working right.  He’s not having a heart attack.  Again, the word they used is cardiomyopathy.  What’s that?

(TODD MASSEY)    

Cardiomyopathy is just really in and of itself a disease process of the heart where the pumping chambers can no longer function efficiently or appropriately.

(PETER SALGO)     

Actually, if you take the word apart, cardio for heart, myo for muscle, pathy, which means disease.  So it’s a disease of the heart muscle.  And he’s in heart failure.  What does this diagnosis imply for Craig?

(TODD MASSEY)    

Usually, it’s a chronic progressive disorder.  The rate of progression though is different in different individuals.

(PETER SALGO)     

So here’s Craig.  He’s flat on his back.  There’s tubes now coming out of him everywhere, because they are rushing to give him drugs and monitor him and save his life really and get some of this excess fluid out that’s cluttering up his lung.  What’s he thinking?  What’s he feeling right now?

(SAMUEL SEARS) 

There’s no question that the severity of the medical situation produces a severe psychological reaction as well.  In many ways, it’s a tremendous threatening situation that both he and his family are experiencing.  It’s a pretty natural reaction to a very serious threat of life.  And I think it really challenges patients and families.  It challenges them to be able to muster the resources, pull themselves together and support each other to get through this.

(PETER SALGO)     

How common is heart failure?  Does anybody have a number?

(TODD MASSEY)    

If you look at the incidence of heart failure per year, in new cases of heart failure, you’re roughly talking about six hundred thousand new cases of heart failure per year.  If you look at sort of what we would consider in stage heart disease, you’re really talking about two hundred fifty, three hundred thousand new cases per year.

(PETER SALGO)     

Now, Paul, I know you said you had a heart attack.

(Paul Smoker)          

Yes.

(PETER SALGO)     

But heart attack and heart failure are not the same thing.  Some people have heart attacks and never go into failure.  You did.

(Paul Smoker)          

Yes.

(PETER SALGO)     

So you heard the words heart failure.

(Paul Smoker)          

Yes.

(PETER SALGO)     

Did that have a resonance with you?  What were you thinking?

(Paul Smoker)          

I actually think I was in denial. 

(PETER SALGO)     

Okay, how so?

(Paul Smoker)          

I didn’t—at the time I first heard the words heart failure, I didn’t have any of those symptoms or feel any of those symptoms.  I felt fine.  And my cardiologists had put me on a regimen of various drugs that helped me feel fine, bring my blood pressure down, etc., etc., and I didn’t have those kind of symptoms for years.  And then this went on probably about eight years.  And towards the end, probably the last couple of years gradually I started to feel worse and worse and worse and worse and worse.

(PETER SALGO)     

When they finally said, “Your heart has failed,” the end of the line you have heart failure, what did you think?

(Paul Smoker)          

Well, talking to my cardiologist, he said, “We have a decision that we can make.  I’ve taken you as far as I can take you on drugs.  And we can give you some other drugs and send you home and you’ll feel fine.  And you might have a fifty percent chance of being here next year.”

(PETER SALGO)     

End of the road.

(Paul Smoker)          

You got a fifty percent chance of dying within a year.

(LISA HARRIS)         

You know, Peter, I got to wonder the message that we send to patients when we talk about hypertension and with heart attacks.  We’ve come so far with our technology and our management of heart attacks, that I think patients think that if they’ve survived the heart attack, that that’s really—they’ve achieved something.  That’s really all that happens.  And don’t understand all the complications that can occur post-MI, or even if they have high blood pressure.  And the consequences of having uncontrolled hypertension.  So people hear heart failure and don’t really understand what we mean by that term, because we’ve got good drugs to help manage that.  And if you don’t have symptoms, what are you talking about?

(Paul Smoker)          

I think that was true in my case.  I just went about living my life the way I always had.

(CATHERINE FARNAN):    

I think people are in denial until it really impacts their life.

(LISA HARRIS)         

Right.

(CATHERINE FARNAN):    

You know, until they have trouble walking across the room, going up those steps, feeling short of breath.

(PETER SALGO)     

When the meds start reaching the point where they’re not working anymore, because the heart disease is getting worse.

(LISA HARRIS)         

That’s right.

(TODD MASSEY)    

Absolutely.

(PETER SALGO)     

Now, I want to explore for a minute Craig’s symptoms.  There’s no history here that Craig ever had a heart attack, as you did.  But he did have bad high blood pressure.  What else can go and cause heart failure here other than high blood pressure or if he’s had ischemic heart disease, that is to say a heart attack, for example.

(TODD MASSEY)    

One of the other more common causes would be viral cardiomyopathy.

(PETER SALGO)     

An infection.

(TODD MASSEY)    

Where you actually get a viral infection of the heart, and then subsequently can fail.  Now, we have individuals that have postpartum cardiomyopathy.  You can have it after pregnancy or during pregnancy.  You can have autoimmune diseases.  It also can affect cardiac function.  The most common cause will be coronary artery disease.  And the second most common is idiopathic or we just don’t know.

(PETER SALGO)     

What are you going to do?  Craig is now in the hospital.  He’s got the diagnosis of heart failure.  What sort of thing do you want to do acutely, and then how do you want to treat him so he can leave—

(TODD MASSEY)    

You know, the first things to do would be, in this sort of instance, would be trying to get some of this fluid off him.  And actually trying to get the heart to maybe pump a little bit better.  And typically would end up probably putting him on what’s called an inotrope.  But it’s almost like a little bit of rocket fuel for the heart that goes to the IV.  And try to get him symptomatically better.  The initial steps will be number one try, and if possible, to find the cause of it, and treat that.  Even though a lot of times we do not ever identify the individual cause.  It’s more symptomatic treatment. 

(PETER SALGO)     

Well, Craig’s doctors put him on a cocktail.  And this cocktail was an ACE inhibitor, a beta-blocker, nitrate, spironolactone, aspirin, another diuretic.  But this is a medicine cocktail.

(LISA HARRIS)         

Yes.

(PETER SALGO)     

Medicine—the practice of medicine is more than drugs.  Right?  What else would you do for him?

(LISA HARRIS)         

Well, we’d also have to talk about sodium intake and make sure that he’s monitoring his salt intake.

(PETER SALGO)     

So you want to change his diet.

(LISA HARRIS)         

Absolutely.

PS                  

Okay, what else?

(LISA HARRIS)         

And go to cardiac rehab for exercise.  Depending on what his echocardiogram showed and what his ejection fraction was like would determine other things that we may want to do from—

(PETER SALGO)     

The ejection fraction is the percent of blood that is sent out of the heart with each beat.  Normal would be fifty percent give or take.  Bad would be fifteen percent.  What about this cardiac rehab?  What happens there?  That’s something you do.

(CATHERINE FARNAN):    

Typically in rehabilitation, what we’re trying to do is prevent further disability or further damage to that heart.  So for that cardiac rehab patient, we will want to try to keep them stable and not have them digress, but see what their baseline function is so that we can capitalize on that.  Can we add exercise to them.  What can that heart function as, so that they can go back and live a quality life.

(PETER SALGO)     

So what’s your goal?  I heard words that most people wouldn’t think you’d want to do with a guy with a bad heart, exercise, I heard.  How can somebody with a bad heart exercise?

(CATHERINE FARNAN):    

Well, the heart is a muscle.  And exercise has been shown to really strengthen that muscle mass.  And hopefully through that prolonged exercising, that endurance level will change, so that that person can have some improved function.

(PETER SALGO)     

How many of them are clinically depressed do you think?

(SAMUEL SEARS) 

Well, in all heart patients, mental disorders of various sorts around a one out of four, but in these more severe cases, the most recent studies suggest they’re closer to forty-eight percent.  So you start seeing almost half the patients with significant difficulties trying to get through this.  This is where families really get a gut check to like none other.

(PETER SALGO)     

Let’s put this in context again.  Here’s a guy.  He’s on a bunch of medications.  He’s in cardiac rehab.  You’re getting him out of bed.  You changed his diet.  Is his heart ever going to get better?

(TODD MASSEY)    

Can it get improved?  It can potentially with these medications.  And some of these medications are beneficial in actually restoring function.

(PETER SALGO)     

So you can treat him.

(TODD MASSEY)    

You can treat him.

(PETER SALGO)     

But you’re not necessarily going to cure him.

(CATHERINE FARNAN):    

But I just want to make a point here.  Rehabilitation is not curative.  It’s restorative.

(TODD MASSEY)    

Right.

(CATHERINE FARNAN):    

So hopefully through some of the exercises, there will be some improvement, but it won’t bring that heart back to fifty percent.

(PETER SALGO)     

And just to make a point, if his heart is not pumping effectively, if there’s less cardiac output, the end organs, the organs that receive blood from the heart, they’re going to get hit as well.

(TODD MASSEY)    

The way I look at the heart, I mean, is a muscle that provides power to your entire body.  And, you know, if your power station is shutting down, some of the lights start to go out.

(PETER SALGO)     

All right, let’s pause just for a minute and kind of sum up what we’ve been discussing.  Cardiomyopathy, heart failure, means that your heart can’t pump enough blood to meet your body’s needs.  While it is generally not reversible, it is treatable.  Is that fair?

(TODD MASSEY)    

That’s fair.

(PETER SALGO)     

All right.  Well, I can tell you that for a while, Craig with his rehab, with his medicines felt better.  But he was being hospitalized again and again, more and more frequently.  Does that sound familiar?

(Paul Smoker)          

Yes.

(PETER SALGO)     

And about a year after this heart failure diagnosis was established, he was back in the Intensive Care Unit for kidney trouble.  Again, kidney trouble I’m assuming because his heart wasn’t pumping enough blood to the kidneys to keep them healthy.  And his doctor said he was in late stage heart failure.  Now, what does that mean late stage heart failure?

(TODD MASSEY)    

They’re typically talking about what is called Class D heart failure, end stage heart disease.  It’s where you’re reaching the end of the life of that heart.  Medications have sort of run their course, and there’s just not a lot of hope left.

(PETER SALGO)     

Now, you’ve only got one heart, only one heart.

(TODD MASSEY)    

Right.

(PETER SALGO)     

And when you’ve run out of rope with the heart, what do you have to offer?

(TODD MASSEY)    

Either cardiac transplant or some of the newer artificial heart devices that we have available.

(PETER SALGO)     

The LVAD.

(TODD MASSEY)    

The LVAD.

(PETER SALGO)     

That stands for left ventricular assist device.

(TODD MASSEY)    

Yes.

(PETER SALGO)     

Can you show our audience a little bit about—

(TODD MASSEY)    

The older devices are the pulsatile devices.  They were either electrically or pneumatically actuated.  In individuals that had those, you would actually feel a pulse.  These newer pumps that we’re using, this one being the HeartMate II, which is a form of continuous flow pumps that are being utilized.  By continuous flow, we mean it’s not pulsatile.  The flow is always going.

(PETER SALGO)     

So if somebody is on this, I just want to be clear, whereas the older devices went lubdup or lubclank, if you will.  They were loud.

(TODD MASSEY)    

Yes.

(PETER SALGO)     

This thing just spins.

(TODD MASSEY)    

It spins.

(PETER SALGO)     

And so somebody that is being kept alive on one of these pumps doesn’t have a pulse.

(TODD MASSEY)    

They do not.

(PETER SALGO)     

In any event, you’re a surgeon.  Where does it go?

(TODD MASSEY)    

The pump’s actually positioned over the abdominal area.

(PETER SALGO)     

It’s below the diaphragm.  It’s not in the chest.

(TODD MASSEY)    

Right.  It actually, I think one of the nice features of that for this pump would be if you ever needed to go back to doing anything to the pump, you can actually not have to re-enter the chest.

(PETER SALGO)     

Okay, now, this part goes to the heart?

(TODD MASSEY)    

This part goes to the left ventricle and actually goes in what we call the apex of the heart, or the very pinnacle of the heart.  If you think of the heart, it’s almost shaped somewhat like a triangle.  This goes within the left ventricle.  And this goes to your aorta, which is the big blood vessel that takes blood to your body.  Your heart remains in you.  Your heart does not necessarily have to function though.  We’ve certainly had this pump in individuals where their aortic valve never opens again.

(PETER SALGO)     

The aortic valve is the valve out of the heart to the body.  So essentially, what you’re saying is you’re using the heart as a conduit to carry blood to this device.

(TODD MASSEY)    

Yes.  This is the driveline.  It comes out of the abdominal wall where we then are able to hook this up to batteries, so that individuals can be out and about doing their normal stuff.

(PETER SALGO)     

Sitting next to me is somebody who’s got one of these things spinning away as we speak.  You’ve got one of these inside.

(Paul Smoker)          

Inside.

(PETER SALGO)     

And it’s spinning away.

(Paul Smoker)          

Yes.

(PETER SALGO)     

These are batteries.

(Paul Smoker)          

Right.  These are rechargeable batteries.  And they last about four hours.

(PETER SALGO)     

Now, you just pulled a battery out of this.  That can’t be good.  If I left it out, it would be some serious stuff.  But this is the controller.  And this little button right here tells me that I have about fifty percent power left in these two batteries before I have to change them.

(PETER SALGO)     

But let me back this up a little bit, because this is amazing technology.

(Paul Smoker)          

Yes, it is.

(PETER SALGO)     

Yet, Craig is sitting in the hospital.  He still has his own heart.  Why would they offer him this as opposed to let’s say a heart transplant?

(TODD MASSEY)    

You know, in Craig’s story some of the things that would potentially be a problem would be his renal insufficiency.

(PETER SALGO)     

Kidney failure.

(TODD MASSEY)    

Kidney failure, which could be from his high blood pressure.  Not necessarily only from the heart.  One of the other things is it sounds like he was a little bit overweight, which that could preclude you from heart transplant as well.  The heart transplant selection criteria are fairly significant as far as individuals who qualify for.  The reason it is that way is there’s certain things that could be detrimental to you if you had them and you got a transplant and had to take immune suppression drugs.

(PETER SALGO)     

But the message here is that this is not—we used to call these bridge to transplant.  You put this machine in while you waited for a heart.  Craig by the way was told not only there were other issues precluding his getting a heart transplant.  But genetically, there was a problem getting a good match.  And he was too sick to wait in any event.

(TODD MASSEY)    

Right.

(PETER SALGO)     

But they put this machine in Craig by the way.  And he was going to live with it.  Not wait for a transplant.

(TODD MASSEY)    

I think, you know, heart transplant, great therapy, and certainly in my mind is still the gold standard.  Unfortunately, the problem with heart transplant is the lack of available organs, and especially in a timely manner.  What we’ve always needed was hearts on a shelf.  If I had hearts on a shelf, I’d be doing them all day in the OR.  With this newer, current technology, we’re approaching that.  These are becoming hearts on a shelf.

(PETER SALGO)     

To some degree though that’s got to be based on how people do on these machines.  And what is it like living with this machine?

(Paul Smoker)          

It goes into me right here, the driveline, and I can feel it.  It goes up here, and it’s hooked into the pump right there.  I can feel that.

(PETER SALGO)     

How long have you had this thing in?

(Paul Smoker)          

A year.

(PETER SALGO)     

So it’s been a year.

(Paul Smoker)          

Just a little over a year.

(PETER SALGO)     

And does it bother you at all that you’re tied to this device?

(Paul Smoker)          

No.  I’m alive.  And I’m back to doing what I do, which is, you know, I teach music and I play music.  I feel better than I have for a long time.

(PETER SALGO)     

Is he typical?

(SAMUEL SEARS) 

Well, the outcomes with LVADs have been very desirable in these key areas of quality of life.  I mean certainly this is a bad disease state that we’re managing.  So it’s not the panacea by any means.  But in particular in his case, I think he had a destination where he wanted to go is destination therapy LVAD.  But his destination was getting back to playing music.  He had a very specific set of goals and get back to his fantastic wife and family.  That he had a specific life that he wanted to return to.  And so in that way, we achieved what—it sounds like the medical team achieved what they wanted to achieve medically.  But he achieved what he wanted to achieve from a quality life perspective.

(CATHERINE FARNAN):    

It’s critical when the LVAD goes into a patient that that family begin to understand what that means from a psychological standpoint, from a health standpoint.  But we really have to educate the patient on the device itself, knowing the alarms, educating the families to those alarms, making sure that driveline does not get infected.  Just really understanding everything you can about that device to live with.

(PETER SALGO)     

Walk me through something.  Craig went ahead and had the device.  It’s now day one, day two, day three.  He’s been pretty sick.  His kidneys were shutting down, short of breath.  Now, he’s got this device in.  What is his life like and how does he climb back out of this pretty deep hole he was in?

(CATHERINE FARNAN):    

Well, hopefully, his life is a lot better than it was prior to the surgery.  What we’re trying to get that patient to do is get up, get out of that bed, start to learn how to troubleshoot that—this device, how to manage the batteries, all the things that are going to make him become more functional and live his life.

(Paul Smoker)          

My support is my wife.  I mean she’s been just incredible through this whole thing.  And to have that kind of support and still to this day, I mean, she’s reminding me change these batteries.  You know, she hears the beep go off before I do sometimes.  She’s been just incredible.  And that’s been very, very important.

(SAMUEL SEARS) 

That’s a very typical response.

(Paul Smoker)          

To my success.

(SAMUEL SEARS) 

Yeah, that many cardiac spouses report, you know, that they’re working harder at it than the patients some days.  And that is—

(Paul Smoker)          

I mean she’s been great.

(SAMUEL SEARS) 

That’s sort of the privilege and honor we have to be around families at this collision point of life and death is that, man, you see some toughness and some love that you don’t see in daily life.

(LISA HARRIS)         

Paul said something else that was really significant.  You know, earlier on you said that you were feeling fine, and your doc was giving you meds.  And now you said that you feel better than you did over the past five years.  So spouses and patients really need to pay attention to your symptoms.  Have you noticed subtle changes that you can’t do the things that you used to do.  Those are things that you need to bring back to your physician.

(Paul Smoker)          

Well, she knew all of those symptoms before I did.  I was in total denial.  I don’t need this.  I don’t want anybody cutting my chest open.  What is that, you know?

(TODD MASSEY)    

You know, chronic heart failure is such an insidious process.  This is not uncommon what you’re referring to.  We see individuals and, you know, you talk to them.  You’re like, “How are you doing?”  And they go, “You know, I’m doing pretty good.”  But what they think is doing pretty good.  If you could wave a magic wand and make one of us feel like that, we’d probably think we were dying.  And it can happen so slowly over time.  And it’s not uncommon what we see after putting these systems in.  Individuals go, “Boy, I haven’t felt this way in ten years.  I feel great, you know, I can go do things.”

(Paul Smoker)          

Yeah, in hindsight, you know, I mean, why didn’t I do this before? 

(TODD MASSEY)    

The biggest thing is that quality of life benefit.

(PETER SALGO)     

I want to pause just for a minute and sort of sum where we are.  There’s so much to talk about, but I do want to point out that while heart transplant was once the only hope of survival for heart failure patients.  These Ventricular Assist Devices, the LVADs are now being used successfully.  Not as a bridge to carry you to transplant, but as a permanent treatment sitting right here.  A year later.  It’s two years after his LVAD.  Craig has returned to work.  Guess what he does, Lisa.  Do you want to guess?

(LISA HARRIS)         

He’s a doctor.

(PETER SALGO)     

He is.  He’s a family physician.  One wonders how a family physician would let himself get that sick.

(LISA HARRIS)         

We’re the worst patients.

(PETER SALGO)     

You are the worst patients.  Paul, it’s been your year.  A year on this device.  Are you back playing music now?

(Paul Smoker)          

Yeah.  Yeah, I’m playing tomorrow as a matter of fact.

(PETER SALGO)     

That’s amazing.

(Paul Smoker)          

It is.

(PETER SALGO)     

And it just—you look great.  Your color is good.

(Paul Smoker)          

I feel good.  Yeah, I feel good.

(PETER SALGO)     

Is he your typical patient?

(CATHERINE FARNAN):    

It’s this resiliency that makes us want to go back to work every day and make this happen for that quality of life is function.  He returned to what he loved to do.

(PETER SALGO)     

This is just amazing.  Great technology.  Great stuff.  Well, you did say one other word, time.  And that is what we’re out of.  So I want to thank you especially for coming here and sharing your story with us.  All of you for helping us understand this technology.  But, yes, you can continue this conversation on our website, secondopinion-tv.org.  Where you’ll find transcripts, videos, and more about heart failure, heart replacement, and other healthcare topics.  Thank you for watching.  Again, thank everybody on this panel for being here.  I’m Dr. Peter Salgo, and I will see you next time for another Second Opinion.

(SPEAKER) 

Major funding for Second Opinion is provided by the Blue Cross and Blue Shield Association.  An association of independent locally operated and community based Blue Cross and Blue Shield plans, supporting solutions that make quality affordable healthcare available to all Americans. 

(SPEAKER) 

Second Opinion is produced in association with the University of Rochester Medical Center, Rochester, New York.