Episode 4 - Spring Summit Recap

Join our guests Ben Alencherry, MD, Joseph Pietrolungo, DO, FACC, and Andrea Robinson, MSN, ACNP, AACC as they recap key points from the 2022 Spring Summit of the Ohio-ACC Chapter. They cover device selection for left atrial appendage closure, an overview of cardiac amyloidosis, and a review of the top five clinical trials from 2021.


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Transcript

Kanny 0:04

This is the cardio Ohio podcast, the presentation of the Ohio chapter of the American college of cardiology. This is canny gray wall president of the Ohio chapter and host for today's discussion. Further information about this podcast, including speaker biographies, as well as references are available@ohioacc.org. Where you can also provide feedback and suggestions for future topics. The podcast will also be available for download wherever you access podcasts, and we encourage you to subscribe, to receive updates on future sessions

0:46

I'd

Kanny 0:46

like to welcome everyone to our fourth episode of the cardio HIO podcast. Today. We'd like to have a special episode to recap. What I thought was an excellent meeting that was just held in the last few weeks. the 20, 22 spring summit for our Ohio chapter. This was a half day meeting and it really covered. Extreme variety of topics, all of which were very timely and all of us were very clinically focused. So I'm really happy to have three members of our planning team for that meeting. Joining me today to recap just some of the really key teaching points and practical points from a few of the times. I just like to introduce our panel first from here in Columbus, we have Andrea Robinson. She's currently the CB team committee chair for the Ohio chapter. She's also a practicing nurse practitioner here at Ohio health with a focus on electrophysiology, Andrea welcome, but also like to welcome from Cleveland Ben Allen Sherry Ben is a final year fellow at the Cleveland clinic. He was part of the planning team and one of the presenters at our spring summit. And, he also will be continuing, I believe his training at the Cleveland clinic and cardiac imaging. Correct me if I'm wrong, Ben and welcome

Ben 2:08

Dr. Gray wall. You're correct. And, thank you. I'm excited to join.

Kanny 2:13

You'll be hearing more about that as well as some of our future episodes is he has a. Going to continue to be involved with some of our future podcasts. And then finally last, but certainly not least from Akron, I'd like to welcome Joe Petro Longo. He's a current trustee on the board of trustees for our Ohio chapter. He's been involved in the chapter and contributed in numerous ways over the years. He's an invasive non-interventional and vascular specialist at Summa. And. Joe

Joe 2:42

welcome. I'm Kenny. Thanks for

Kanny 2:45

having. Yeah, appreciate all three of you joining me, Andrea. I thought we would start with you. one of the, what I thought was one of the excellent talks at the spring summit was by Dr. Christopher Ellis and he was discussing closure devices for left atrial appendage, Dr. Ellis emphasized several things in his talk. first of all, I just thought I'd ask you since you're a clinical practitioner in EAP and see a lot of these patients with a fib. why do you think there's such a need for these devices now? And why do you think their role is growing as a treatment option for patients with atrial fibrillation?

Andrea 3:24

Well, I, I think certainly as the number of options for patients grow, it just increases the, our ability to treat them appropriately. You know, I kind of go through some of Dr Ellis's points, but there's a lot of niche cases out there that. You know, prior to the approval of some of these surgical devices and that's all as the epicardial devices, there really just wasn't anything. And so a lot of patients would just go either untreated and at risk for stroke, or they press on with anticoagulation and have risk for bleeding. So the game has really changed over the last decade. and I think Dr. Ellis did a great job going to going through some of those ups.

Kanny 4:03

So we've been using the Watchman device for several years. I think most of us are comfortable referring patients for that device. And, Sam good success. what were some of the things he outlined in terms of the need for additional devices or ongoing challenges with this class of devices?

Andrea 4:21

Sure. So he started out by showing a couple of case studies. the first two were both patients that had persistent left atrial appendage thrombus. One was in a setting of severe LV dysfunction, which was then. Treated with a CRT device with an AB junction with improvement of LV function, the LAA thrombus resolved, but then unfortunately she had a mechanical fall and eventually succumb to complications from intercranial hemorrhage. The second patient had persistent LAA thrombus, and this was even decided. Systemic inequality relation with a DOACs. So with that, he transitioned to review some of the data for epicardial LAA closure, which I think some people are a little bit less familiar with in 2021, Laos three was published, which is actually the largest left atrial appendage closure trial. There is, and this was comparing surgical closure. No surgical closure and patients undergoing cardiac surgery and had a five-year followup and did show a 37% reduction in all strokes. When the LAA was included. Dr. Ellis reminded us to keep in mind that this is sort of a belt and suspenders approach for patients and this trial, because they did continue on anticoagulation. And this was secondary. There really was no formal regimen to do follow-up confirmation imaging to confirm closure. To allow safe discontinuation of inequal relation. but the benefit was, you know, this did show really good successful closure rate, I suppose, using the atrial clip device at 95%, he also went through and, reviewed some of the data on Lariat. This is another epicardial closure device that is considered a non-surgical or minimally invasive, and this done with either, an electrophysiologist or an interventional cardiologist. Some of the data on this, isn't quite as robust for the closure rate. it does start to success between around 60 to 70%, which is not as, as successful as atrial clip, but he did point out that when it is a hundred percent occluded, it does have a similar observed stroke rate, which is quite low. His really big takeaway from those epicardial devices is that these are really appropriate for patients who have refractory LAA, thrombus, despite anticoagulation possibly have risk factors for putting an endocardial device in or patients with prior intracranial hemorrhage that you really want to eliminate the need for any antithrombotic therapy at all.

Kanny 6:53

Joe, in your, clinical practice there in Akron, are you seeing the atrial clip being used on a more routine basis with patients who are already undergone open-heart surgery? Cause I think that's certainly been what we've seen here in Columbus.

Joe 7:05

Yeah. Actually can, we are it starting to creep into the standard of care here? slowly but surely and. In fact, the, there was a case we were discussing recently, one of our valve conferences and the surgeon was talking about what his plan was, and it certainly included in a patient without atrial fibrillation and no mitral valve disease to put a left atrial closure device. And

Kanny 7:32

so, Andrea, I know he also talked a little bit about advances and new options for interventional plays devices.

Andrea 7:40

Yeah, he did. So I think, you know, I think most everyone is pretty familiar with the data on Watchmen, even up to the 2.5 generation. So, you know, I won't review any of that data, but he did review pinnacle flex, and this is what the newest generation updated design of Watchmen. That's now commercially available. Pinnacle flex demonstrated even improved safety from protect and prevail with zero device embolization, zero pericardial effusions that required drainage and a 0.5% major complication rate. And the efficacy was also great as well with near a hundred percent implant rate, and follow up nearly 90% of the patients did have no detectable flow. So really, really great continued, safety and efficacy with clinical flex. He also reviewed amulet. This is the newest commercially available endocardial device, and it's a little bit different design. It's a disc and hub device. This has placed in a more proximal position than Watchmen and, and that IDE trial had compared head to head with Watchman. What he pointed out that he bought was, was most notable is a PDL or pear device leak was seen and less patients receive an ambulance. Then with Watchman implant, success remain Thai and ambulant safety favored Watchman, by a small amount. And it did demonstrate shorter procedural time. he relates this as likely to the operator, experience curve with Watchman, some of the secondary end points for DRT, slightly favored, ambulance and intercranial hemorrhage, data of slightly favored Watchmen. but another benefit is that amulet labeling does not obligate the patient to inequal relation. And you are able just to use dual anti-platelet therapy immediately following implant. You also pointed out there are some unique, left atrial appendage anatomy, which favors aimless as well. So really his key takeaways regarding the endocardial left atrial appendage closure devices is that, if a patient has, typical LAA anatomy and the focus is on getting your patient through a procedure quickly and safely with a high chance of success, Watchman flux would be your device. Downside, as you can still see some pear device leak, some of which unseen and follow can increase over time and thus will carry that a 2.5% chance of device-related thrombus. And then the FDA labeling still does require anticoagulation for six weeks post. Takeaway for ambulant is that, you know, if you really are focused on wanting to place a device with no true pair to buy sleek, and you may be able to use, some more challenging anatomies. And if you want to avoid use of anticoagulation, then amulets or device of choice, he did also point out though, and about 80% of patients, it really is toss of the coin. Both ambulant or watch from flux would be appropriate for the majority of patients. So I think my overall takeaway from the entire talk is it's great to have options. so I guess this kind of brings up a question to me is that, as. But it out to the group as a referring cardiologist, are, are you guys now referring for a specific device based off of patient characteristics or are you just referring for a general evaluation for left atrial appendage closure?

Joe 10:59

well, I have to tell you that I, the, the EAP guys down here they're mostly doing Watchman at this point. we're not seeing a lot of ambulance yet. although I think it's probably going to come on when we, send our patients to them, for these considerations. most of the time, they're, they're making decisions on whether they're a candidate for a Watchman procedure. So we don't, you know, we're not really getting involved in making the decision on which device they're going to implant

Kanny 11:28

yeah. I would agree with that here in Columbus as well, that when we have such a robust, structural. multidisciplinary program that we usually would defer to them. And we just have a little bit of experience with ambula, which has been very positive so far. Ben, how bout in Cleveland? on the services you've been working on, do you feel like, it's pretty much left to the structural team to decide how to proceed with a specific device or, or approach.

Ben 11:52

you know, as, as the cardiology fellow will admit some of these patients beforehand with a GI bleed and that's how their candidacy is revealed. And for the most part, all of the referrals, the electrophysiology team is, is selecting the device type. I wanted to also pose this to Andrea, you know, as a fellow, we will see the patient beforehand and we'll do the T E after placement at the intervals. we just want to know from your experience, because you interface with the patients afterwards, we always hear about the bleeding that is subsided after coming off anticoagulation, but can you speak a little bit from the patient perspective, from what they're telling you? You know what life is like now coming off of anticoagulation

Andrea 12:37

yeah. it's all over the spectrum. I think now with, previously we're only in planting and patients that were very high risk of bleeding. And so those patients were in and out of the hospital or in and out of the endoscopy suite, trying to get temporized in order to even allow short-term anticoagulation for the procedure. So. You know, those patients inherently had better quality of life, less anxiety, but even for the other patients that, maybe it was a little bit of a softer indication of, they're using a wheelchair or they're using a cane and a Walker and they've had a couple of falls or near misses. And for them, it was more than. Prevention. And it's just taking away a little bit of the anxiety of worrying about a major fall. Especially as we look at some of the newer clinical trials, such as with the option and champion, we're going to be implanting these and healthier patients. if those trials are positive. And so it's not just going to be people having that major, significant lifestyle improvement with lack of bleeding, but just kind of opening up the ability to kind of do the things they want to do and not be so concerned about things.

Kanny 13:42

Well, thanks, Andrea. I think that was a excellent summary of a very detailed. Presentation that I think is a topic we're going to continue to hear a lot about. So Ben I know you, helped put together this very interesting session on the top trials of 2021. can you just fill us in on how you and the other fellows, went through that process? that was Alex Miller and Farhan Nasser who joined you in that present?

Ben 14:07

Yes, so first I just want to say it was a, it was a great experience for fellows and training to be a part of the trial review. Alex Farhan and myself. We had to work as a team to kind of pick the top five trials that we thought, represented the different disciplines in cardiology in 2021. And we left some off, obviously it's difficult to narrow it. But we, we started by just identifying which discipline we, we wanted to cover. So, so first I'll just describe the five that we picked, with a clinical summary, a one-liner of how it applies to, our relevant sort of clinical practice. So first was the, was the loop trial. and you know, this was a study about AFib and, and. The surveying patients before a clinical event and clinically, we thought this was relevant because the consideration of preemptive AAF management, and should we implant loop recorders in patients to catch a AFib, ahead of an event, this trial really was a large trial that showed that there was no difference in clinical outcomes. So we thought this was important because regardless if you're an electrophysiologist or a general clinic, You know, it pertains to your patient. Who's asking, you know, should we actually monitor me for atrial fibrillation to reduce stroke risks? And we found out that through this trial there, no difference. The second trial that we went over was in the structural heart realm. And that was the avatar. As Taver becomes more of an option. The, the question of in asymptomatic patients with severe aortic stenosis, should we intervene before a clinical symptoms manifest? Is there any benefit to that? This study tried to assess that. Overall the study was basically asymptomatic patients who had to have an exercise treadmill, stress test and had to be negative in terms of they had no exercise limitation for their age and gender. Do these patients do better or worse? Upfront aortic valve stenosis, and this was surgical aortic valve stenosis. So they found that there was a difference in hospital, heart failure, hospitalization in those patients who got preemptive surgery in that they didn't wait for symptoms, but you know, this was a, this was a small truck. that was done mainly at one center in Eastern Europe. But I think the reason why we picked this one was as Taver becomes more of an option, your patient, who is 70 years old, who has severe AIS and doesn't have symptoms, would you then offer a Taver because that's less of a surgical risk obviously than sever. And this is a compelling study that hopefully sheds light on that in the structural heart rate.

Kanny 16:45

Thanks Ben, regarding your first study, the lip study. I thought that was a very, very interesting study because, you know, I'm sure the other clinicians would agree that use of implantable loop recorders has kind of exploded in recent years. And it's always been a question of a lot of clinical cardiologists. You know, what is the clinical relevance of incidentally detected atrial fibrillation, Andrea. A study, like that might change how we use ILRs or do you think there's just more to learn about, you know, the clinical implications of, of any arrhythmia you might detect?

Andrea 17:20

Yeah. I mean, I think that's, it's, it's still pretty controversial, you know? I mean, especially in electrophysiology where, you know, we're not necessarily implanting them for. Diagnosis. We know romaine, you know, we implant a lot post procedurally, after ablation to follow their burdens. And even that, you know, I think has changed in the way we think about things. You know, we used to think about ablation failure as if there's 30 seconds of atrial fibrillation. Now we consider it actually ablation success as if you can decrease their burden over time. And I think that. You know, loop still provide a lot of value in the ability to do that. you know, there's definitely still a, you know, a great role for monitoring for cryptogenic stroke, but, you know, I thought this, and this was a nice study and I'm glad that, that it was presented, even though it wasn't, you know, it wasn't a positive study, but you know, I do still think that there's a, a very good role for these long-term cardiac monitor.

Ben 18:18

And Andrea, you brought up a great point. That was a question we had was the authors use six minutes as a cutoff for atrial fibrillation. And I think this is thought provoking is how much a thread is, is too much or too less than the authors use six minutes. But I know that's been a point of discussion.

Andrea 18:33

Yeah, it definitely is. It's still a controversial topic of exactly how much. If you take, six minutes versus six hours versus 24 hours and you dichotomize that. Against their actual CHADS-VASc score. You do see this relationship, but even when patients have very low burden of aphid, but very high CHADS-VASc score, there is still stroke risk there. On the other hand, if you take very low CHADS-VASc score and high F burden, you know, it goes to the inverse relationship. So I, you know, I don't know if it's ever going to be as simple as picking a perfect. Time and, and basing anticoagulation recommendations off of that. I think it's a little bit more of a complex analysis.

Kanny 19:15

So Ben, what other studies did you want to highlight? Yeah,

Ben 19:19

so far our third one, we went over the master debt trial and this was a multi-center randomized controlled. Was a non-inferiority trial, basically trying to answer the question in high-risk patients who are high bleeding risk and high ischemic risk. After a percutaneous coronary intervention does one month of dual anti-platelet therapy. Is it non-inferior to six months. Now, this trial has a bunch of limitations. They use specific type of second generation, drug, eluting, stents, but they found that it was in fact non-inferior. and I think the real way that this applies to not only interventionists and cardiologists, but also. Internist as well. And providers who interface with patients who have had interventions is when can we safely take patients off, dual anti-platelet therapy, after an intervention.

Kanny 20:07

Joel, you're very close to this and your practice there. have you seen a trend towards more specialty? DAPT recommendations. I know this could be an entire podcast in itself,

Joe 20:17

you know, can this, this, this topic is quite variable depending on the interventionalist and, and. Probably the similar to what's going on with you guys in Columbus. If there is a special circumstance that comes up with a patient, then sometimes we'll have a dialogue before we do the intervention and talk about, you know, gap, how long, how much, what drugs and, and we'll, we'll work something out. most of the time, the interventionalists, particularly if it's a complex PCI, they want DAP longer than I would necessarily want to have it. So there's just quite a bit of variability. I will tell you that. That with the population of patients that we have, the age, the comorbidities, I see a lot of, of anti-platelet related complications hemorrhage. And of course, with the overlay of the atrial fibrillation epidemic, it's even more, an important issue. So I'm, I'm a fan of deescalating doc, as soon as possible.

Kanny 21:25

Yeah, I agree that, at least it's nice when you have a clinical need to deescalate that now there's more data to help support the decision. So it's great to have more studies like this to help, help clarify that. What else do you have Ben?

Ben 21:39

Yes. So for our last two, we wanted, different settings, one trial that addressed the global need and one, that kind of addressed Hef pep, cause that's a new, sexy topic. So first for the global need, we went over the. The SSA S S trial. So salt substitute and stroke study. We thought this was a really remarkable trial that was conducted in five provinces in China, where they, they cluster randomized patients and they, or participants. They gave for the intervention, potassium chloride instead of sodium quiet. So basically a salt shaker with potassium chloride was given to every family. And what they, the clinical question was, was the salt reduction, the sodium chloride reduction in the diet lead to a hard outcome reduction of stroke. And they did this over five years and it was a very eloquent study and the primary outcome, which was just stroke. So it wasn't a composite outcome. Stroke was statistically significantly. Just by doing this low, low cost intervention. So I think it's really important, especially on a global scale. But it can be applied to we'll just say the United States, because a lot of our issues are hypertension related stroke, heart disease. And as we're dealing with new pharmaceuticals that costs a lot of money. This is a very low cost intervention that I think can be applied to our patients right away.

Kanny 23:03

yeah, well, I think that's a very well done and relevant study that hopefully will have an impact on our preventive practice.

Ben 23:10

Yeah. The, the last study that we went over was probably the most famous of the year was emperor preserved. And so, you know, that was based on the backs of SGLT two inhibition and Hef ref in diabetes and renal disease and all these significant outcomes. Obviously, as we know now, Amper preserved was in the heart failure with preserved ejection fraction, population with EDF greater than 40%. And they randomized one-to-one using empagliflozin and their primary outcome was, heartfelt hospitalization and CV death, this composite endpoint. And it was statistically significant. Now. In these composite end points there it's usually heterogyneous driven. And in this case it was driven more by heart failure hospitalizations, but the bigger thing, and you can nitpick the trial a little bit, but the bigger thing was in this population of Hef PEF patients. This is one of the first drugs we have that really moves the needle in terms of heart endpoints. I wanted to know clinically now in practice, are, are, are you prescribing these with your heart failure with preserved ejection fraction?

Joe 24:15

I will tell you that, this is a step in the right direction for half pap from and from as far as we can tell, I, I personally, and I think most of the heart failure team, I can't speak for them all individually, but we're a little underwhelmed with the study. I think if you have a half page. And they are having recurrent hospitalizations. It might be reasonable to give that a try to see if you can help with the hospitalization burden, but, you know, without, cardiac mortality benefit or something else that gives you a good reason to use. a lot of times these people were all in, you know, five, six medications for everything else that's, that's going wrong. And it's kind of hard to sell them on this, unless they're a diabetic, in which case, sometimes you can, you can get it in that way.

Kanny 25:07

Yeah. I agree. I agree. Completely, Joe. I think it's a great first. Uh, hopefully what will be a lot of upcoming literature to help clarify who benefits? I would also refer everyone to our second podcast, in which, Dr. Castle, outlined, in a lot more detail, the details of that study, as well as some of the limitations in that overall presentation, along with Dr. Ken Varian from Akron on, the contemporary management. heart failure. So I would definitely refer anyone with an interest in fine tuning their heart failure management to, refer back to that episode. well, thanks Ben. I, I think that's a tremendous amount of work you and the others did to, bring those forward and summarize them like that. So we appreciate your

Ben 25:45

efforts. It was a great opportunity. Thanks for that.

Kanny 25:50

So our final topic just for the last 10 minutes will be the Wiggers lecture itself. Joe, I know you were involved in, in, in the selection of Dr. Meyer to be the Wiggers lecture, which is quite an honor. Dr. Mauer of course, is on faculty at Columbia. He's a, an expert in cardiac amyloidosis and I thought he just gave a very, very, detailed, but also clinically relevant presentation, not just about therapy and diagnosis, but also about some of the clinical aspects. What did you think were some of the key, take home points from his presentation?

Joe 26:22

Yeah. You know, that now, or really is sort of, a laid back self-effacing incredible expert in the field of amyloidosis. I mean, Matt and his group have contributed. Tremendous amounts to the field. And don't forget, we had, we had mass Hannah who is, you know, equally a, a Maven in the field of cardiac amyloid. And he's really re tooled all of us, at least in this area, on, on, on the correct way to approach this and how. How to really work up and treat this disease. Matt went through all of the major important facts of features of amyloidosis, both AAL and TTR. And not only did he talk about the, the, the, the clinical stuff that's important. And I'm going to kind of mention here in a minute, but you know, he, he sort of gave you a little insight into all the new stuff that's coming as well. And this is a field that's changed rapidly over the last. It's five to 10 years. And I think you're going to see even more tremendous, advancement in this over the next five to 10 years. So some of the highlights, of, of Matt's talk, first, you know, the, he started with, I think something that we all need to keep in the back of our minds is that amyloid is considered a rare disease, but it's probably not rare. Bye clinician definitions, and it's still relatively under diagnosed and undertreated. And that we've, these patients really do better. The earlier you get them into treatment. And that is particularly true of all amyloid. And I always tell the fellows that the best reason to look for a TTR amyloid is to find a Alamo. Because those patients are really a medical emergency and need to get into the system as soon as possible. and it's clear that amyloid doesn't really have any. To the average practitioner, any hallmark in features that would, you know, light up your brain to say this, this person's clearly got amyloid. I mean, they've, in-stage elderly white guy with a heart that's super thick and monstrous, atria and heart failure. No voltage on his ECG. That's not going to be hard for anyone to pick up. But that's not the person, you know, that you want to get into your practice. I mean, obviously you want to make that diagnosis for that patient, but you want to get them long before they get to that stage. And I think that's what some of the nuances are that help us get there and not kind of went over them using. Things like, you know, your clinical suspicion in patients who have heart failure and aren't doing well on heart failure, medications. we know that these patients have a, restrictive cardiomyopathy and he very eloquently went over a lot of the, the, the science behind that looking at pressure volume curves and, and why these people wouldn't tolerate the medications three use for standard half path for even. these patients, have, you know, most are volumes. They use their heart rate to help compensate for their cardiac output. So they don't do well with beta blockers. They don't do well with afterload reduction therapy. They oftentimes will have a narrow pulse pressure and the blood pressures will be on the low side. he also talked a lot about some of the touch points, where we may, get suspicious that a patient has amyloidosis and from a history it's the heart failure. It's the low flow, low gradient AAS patient, particularly with a preserved ejection fraction. It might be someone who has atrial fibrillation in a slow ventricular response or no wave. You know what blocking drugs. And it's a, it may be a patients who have a need for a pacemaker or heart block, of other forms with no good reason. So these are all potential, red flags. We call them for the presence of, of amyloidosis. The orthopedic manifestations that Dr. Hannah has written about extensively are, are important, and we should be using them, in our history of. uncovered some clues to the presence of amyloid and certainly carpal tunnel syndrome, lumbar canal stenosis, and Matt showed a picture of a patient with a biceps tendon rupture. And if they have a thick heart, that person likely has amyloid, without having to do too much more. he highlighted some of the workup for this. He, he talked a little bit about the echo and some of the prototypical findings on echocardiography, most commonly things like a thick heart and big atria, but other more subtle clues that are really important, such as inter atrial septal, thickening, or thickening in the valve leaflets for no good reason. And in particular, our view off thickening, that's another, clinical clue, particularly in a patient who doesn't have a reason to have that, no pulmonary hypertension or, or pulmonary issues. and then he talked a little bit about the electrocardiogram and it's insensitivity. If you're waiting around for low voltage. Paper from Columbia only about a third of the patients that had amyloid had the clinically, the clinical criteria for low voltage. So we want to, we want to try to use low voltage and maybe an index of a myocardial mass. that may help us. the, the other things that he talked about, which are really important are when you finally decide to work someone up for amyloid, it's very important that you are working them up for AOL amyloid and TTR amyloid. Now. Are other forms of amyloidosis that are out there and the larger your centering, the more people you see with this, like here in Akron, you know, we have a smattering of other non AOL or TTR amyloid patients, but the majority of what the clinicians are going to see in practice in this country is going to be TTR amyloid, either the genetic form or the wild. And ALM awake. And when you're working a person up for Amway, you really need a thorough workup for a. It's there's a lot of, papers and, and reports in the literature of people getting TTR, workups, and being treated for TTR amyloid. And in fact, they have AOL amyloid because some of the things we do to work up TTR AOL can look similar. So it's very important that you make sure you, you do your, your free light chain ass. he focused a lot on using, technetium pyrophosphate as a, radio new Clyde. This has really been a boon to the. as you know, most of the, patients required and the myocardial biopsies for a TTR amyloid in the past, and this has helped to save some people from having to go through that. and th the, if you remember some of the earlier papers, that were published in that, and, and, mass Hannah had been involved with these were people who clearly had, you know, high likelihood of having an amyloid. And when they did the power phosphates scans, they were the ones that were positive, really predicted very well that this was going to be amyloid. And you didn't require a biopsy. Well, we're doing many more power phosphates scans on people with just a little bit less of a pre. Probability of having the disease. So some of these scans are coming back, either equivocal or positive in the patients don't have, amyloid. And that's a big issue because to put them in treatment, which is extremely expensive. you really want to be absolutely sure of the diagnosis. So he reminded us to make sure that when we do these nuclear studies and Kenny, I know you do these, to make sure you're not looking just at the blood pool images, but you're looking at the SPECT imaging as well. And that's a very important, part of, making sure that, abnormalities are in the, the tissue of the myocardium and not the blood pool. The, the other thing about, this is. I think any clinician who orders one of these studies probably needs to look at them themselves. We've had a couple instances where our studies were read as negative and they were indeed positive and vice versa. So he, he really, his, you know, he's done a lot of work in, in, in bringing, our phosphate scanning to the forefront. And then lastly, he w did a whirlwind and wonderful focused presentation on, the therapies for amyloid, both AOL and TTR. And, I thought that was really quite phenomenal. We talked about. Where we are today, the state-of-the-art, but importantly, where we're going to be in the next several years or for a lot of new agents coming out for TTR amyloid in particular, including, gene silencing agents, such as patisserie rant and some anti-amyloid drugs, as well as other, stabilizing agents like ACE. So he did a weekend's worth of a review on a topic in, in less than an hour. It was really quite phenomenal.

Kanny 35:37

Yeah, I agree. It was, it was an excellent review. And as an image or myself, I think we've definitely seen a learning curve with the PYP scan over the last couple of years, as, as us images have become more comfortable with the reading. And I think that has cut down on the false positive diagnoses now that we know to, to look at the spectrum of. And not just rely on the ratio allowance. I've also seen an interesting role for serial PYP is, you know, sometimes you have an equivocal reading and I've seen the hematologist order those again after six or 12 months. And sometimes that clarifies things as well. I know we're up against our time, so I just wanted to thank all three of you again for not just, helping plan and put on the spring summit a few weeks ago, but also for joining us tonight for the recap, which I think will be very helpful to our practitioners. some of which didn't get to see those sessions. I want to remind the listeners that all of these sessions we're referring to are actually available@ohioacc.org, which is our state of Ohio website. There's actually links to the videos for all these presentations. So Andrea, Ben, Joe, thank you again for joining us.

Ben 36:47

Appreciate it. Thanks.

36:50

Thank you for joining today's podcast. For more information about the speakers or the topics, please go to Ohio acc.org,