Treating High Risk and Complex Heart Conditions with Arman Kilic, M.D.

Heart disease is South Carolina’s number one leading cause of death. MUSC Health is known for taking care of patients with high risk or complex heart conditions using the latest innovations and technologies. In this episode, Dr. Arman Kilic, a cardiac surgeon and Director of the Heart Failure and Heart Transplant Program, talks about how MUSC Health is helping more people across the state survive life threatening heart conditions such as heart failure and more.

Correction: The podcast states that heart disease is the state's second-leading cause of death — it is currently the leading cause of death in South Carolina.

“As the state’s only heart transplant center, we are looking to support the community and to support the state, and really to do whatever we can to bring our collective expertise across the various clinical domains to offer the most we can to South Carolinians.”

– Arman Kilic, M.D.

Topics Covered In This Show

• Heart disease is an incredibly common ailment. In the U.S., there are five million individuals with congestive heart failure and approximately 250,000 individuals with advanced heart failure who could benefit from either a heart transplant or ventricular assist devices.
• The Heart Failure and Heart Transplant Program at MUSC Health is a premiere, multidisciplinary heart failure center. Its heart transplant program as well as its ventricular assist device program are considered top ten programs in the country, in that they are high volume, overseeing around 90-100 cases per year combined.Academically, the program has also published over 170 peer-reviewed papers on heart failure in 2021, among the highest in the country.
• Mechanical circulatory support is a type of technology that allows a temporary mechanical device to take over the function of a normal heart, assisting the body in receiving regular blood flow. These devices include an intra-aortic balloon pump, a TandemHeart, and an impella device, for example.
• More durable devices, meaning those which are implanted in the body to support daily life, are called durable left ventricular assist devices. These are inserted through minimally invasive surgical approaches.
• Heart failure comes in many forms and can present as either acute or chronic. The two major causes are either ischemic cardiomyopathy, meaning blockages are present in heart vessels, or non-ischemic cardiomyopathy which means heart-failure without blockages.
• Less common causes of heart failure include hypertrophic cardiomyopathy where the walls of the heart are very thick, as well as peripartum cardiomyopathy which develops in women after pregnancy. There is also the possibility of congenital heart disease.
• It is possible to lower your heart failure risk by regularly scheduling visits with your primary care physician as well as heart specialists who can catch heart disease and heart failure as early as possible.
• Cardiogenic shock is one of the most severe forms of acute heart failure requiring immediate attention and often intensive care. MUSC Health has a new cardiogenic shock program that includes a conference line or “shock team” made up of specialists who can hop on an emergency conference call to provide a consensus opinion to cardiogenic shock patients who need highly specific, immediate care.

Read The Show Transcript Below

Erin Spain [00:00:04] Welcome to Advance with MUSC Health. I'm your host, Erin Spain. This show's mission is to help you find ways to preserve and optimize your health and get the care you need to live well. MUSC Health is known for taking care of patients with high risk or complex heart conditions, using the latest innovations and technologies. Dr. Armam Kilic, a cardiac surgeon and director of the Heart Failure and Heart Transplant Program, is here to talk about how MUSC Health is helping more people across the state survive life threatening heart conditions such as heart failure and more. Welcome to the show.

Arman Kilic, M.D. [00:00:43] Thank you.

Erin Spain [00:00:43] Heart disease is South Carolina's second leading cause of death. In 2019, more than 10,000 South Carolinians died from heart disease. Tell me what's contributing to these deaths.

Arman Kilic, M.D. [00:00:54] Heart failure is really a spectrum of disease and ranges in severity, but it is an incredibly common ailment that affects Americans and people across the globe. In the United States, there are 5 million individuals who have congestive heart failure. And when we talk about the spectrum and sort of the most severe cases which we term advanced heart failure, there's an estimated 250,000 patients that could probably benefit from either a heart transplant or a ventricular assist device, which are the surgical therapies that we can offer for the most severe forms of heart failure.

Erin Spain, MS [00:01:27] So, given the life threatening nature of these conditions with heart failure, what types of conversations do you have with your patients about these treatment options? For example, is quality of life more important than living as long as possible? Do they want to receive aggressive treatment? Tell me about those conversations.

Arman Kilic, M.D. [00:01:45] Well, similar to any time that we're considering open heart surgery, which is a very big deal for patients and their families, you know, there is a conversation that's really custom fit and individualized for that particular patient and for their family and their individual wishes and desires. And that can range depending on the individual. But those are absolutely metrics that are discussed, including quality of life. You know, it's not infrequent that with some of these major operations and high risk procedures, that conversations about things like the need for dialysis or a tracheostomy or things where patients may have longer lengths of stay in the intensive care unit and longer recoveries are all things that are discussed upfront with the patient and with the knowledge that without some of these therapies, the risks of mortality and limited quality of life are very, very high without receiving some of these therapies, which may give them a chance at a normal life.

Erin Spain, MS [00:02:38] Let's talk about some of these therapies and what sets the heart failure and heart transplant program, MUSC Health, apart from other programs in the area and in the U.S.

Arman Kilic, M.D. [00:02:48] I would say that we are a premiere heart failure center. We have a multidisciplinary team that consists of multiple members in the Heart Failure Cardiology group, as well as several cardiac surgeons. It also includes a huge staff that includes advanced practitioners, nurses, coordinators, students, fellows. I mean, really a really a big team that takes care of these complex patients who have advanced heart failure. And I would say what sets us apart is one, is that we are a very high functioning and collaborative team that works very well together, very capable team that is able to offer the latest and innovative care to patients. And our philosophy is that when patients come to us, we are able to offer something that's not always surgery. Sometimes that's a consultation or a second opinion where it may entail adjusting their medications or getting them on optimal medical therapy for their advanced heart failure. It may also involve a discussion about surgical therapies such as temporary mechanical support devices for patients who are in shock or an acute heart failure. Also durable therapies such as ventricular assist devices or heart transplants. We are as a program, a top ten program when it comes to the volume of cases that we're doing in the country. So, we are a top ten heart transplant program and we are a top ten ventricular assist device program. And our combined volume is somewhere around 90 to 100 of those cases a year, which is a high volume center. Outcomes are also excellent. We have had several designations for the quality of care that we can provide and that really again is a testament to the entire team and the multidisciplinary effort and the care of these patients. And then finally, from an academic and innovation standpoint, you know, we published over 170 peer reviewed papers last year just in the heart failure space, which is probably the busiest in the country, to be quite honest, as a group. And we're also always looking to push the envelope with clinical trials or with outcomes research. And we're very busy on the academic side as well. And so patients who may have very complex health care needs and may not be a candidate for traditional therapies like a transplant or a ventricular assist device, there are often clinical trials that we can have a discussion about that we're involved in and so that we may be able to offer some innovative therapies as well.

Erin Spain, MS [00:05:06] That's great. And you mentioned some of these therapies and devices by name. Let's deep dove into a couple of those a little bit and describe them to the audience. Mechanical circulatory support. Tell me more about that.

Arman Kilic, M.D. [00:05:17] Yeah. So there are several options for mechanical circulatory support. And what that means as a general term is that we're using a device that allows the heart to rest and it sort of takes over the function of what a normal heart would do. And it allows blood perfusion to the vital organs of a patient, you know, their brain, their limbs, their liver, their kidneys. And so these are devices that allow the body to receive blood flow when the heart is failing. And so, again, there is a spectrum of devices that are used, and we use all of these devices. So things like an intra aortic balloon pump, a tandem heart, a impella device, whether that's an impella cpr, an impella 5.5. And these are all devices, again, that are inserted in different ways. Some of them are percutaneous, which means that we use a needle stick, whether it's an artery in the groin or sometimes the axillary artery, which is an artery that runs under the collarbone or the clavicle. And we're able to, with sort of these peripheral, percutaneous insertion options, are able to put devices in in a very minimally invasive way. That's not a big procedural burden to the patient and allows them to sort of recover as we get them optimized for a bigger operation. And then, it also, when we talk about devices and sometimes we do talk about durable devices or devices where the patient can leave the hospital with it. And there have been patients who survived ten plus years with some of these devices, and these are durable left ventricular assist devices. Now, that does entail an operation, but at MUSC, we're able to offer minimally invasive options for insertion, and that has become our preferred approach. So what that entails is rather than opening the breastbone in its entirety, we just open a small portion of it and then make an incision on the side and go through the chest to implant these devices. We have found anecdotally that patients recover much quicker when we do the minimally invasive approach and some of their outcomes we do believe are improved, including rates of right heart failure, blood product utilization or transfusion requirements. So in general, the operations tend to be less bloody and if they do eventually go to get a transplant, we have found that the technical complexity of the transplant is generally reduced when you're going into a patient who's had their ventricular assist device implanted via minimally invasive way.

Erin Spain, MS [00:07:32] You were talking about this ventricular assist device and people may be a little aware of this category of technology because of pacemakers. So can you compare a little bit how a device like this compares to a pacemaker?

Arman Kilic, M.D. [00:07:44] Pacemakers are, you know, excellent pieces of technology that have been used for years. Actually, a large majority of our patients will have a pacemaker in at the time of either have been ventricular assist device or a heart transplant. The pacemakers are a procedure when they're inserted, so surgeons are no longer required for insertion of pacemakers. They're typically done by procedurals and cardiologists, and they're typically placed under the collarbone, right under the skin or placed in the chest wall. And those pacemakers allow the patient to potentially recover some degree of their heart function when their heart rhythm is better controlled from the device. The devices we talk about, again, we do have some temporary device support options that may be less invasive to the patient, but can allow them to perfused their body. But those are, again, temporary devices. They can't leave the hospital with those devices. And when we talk about the durable devices, like the ventricular assist device, that requires an operation. So in that way it is different from the pacemakers.

Erin Spain, MS [00:08:42] I want to back up a little bit and talk more specifically about heart failure. Tell me about the different types of heart failure.

Arman Kilic, M.D. [00:08:49] Heart failure comes in several forms patients can present in multiple ways. There's acute heart failure, which can happen to patients who've never been to the hospital before. They may not have no known history of heart failure or chronic heart failure. So patients who've known they've been in heart failure, whether that's for days, weeks, years, decades. And in terms of the causes of heart failure, there are several different causes of heart failure. The two major causes are what's called ischemic cardiomyopathy, which is heart failure that exists in patients who have known coronary disease or blockages in their heart vessels. Nonischemic cardiomyopathy is a little bit more of an umbrella term that relates to patients who do not have coronary blockages or heart vessel blockages, but have heart failure and failing hearts. There are also other, less common causes of heart failure. This would include things like hypertrophic cardiomyopathy, where the walls of the heart are very thick, and over time this leads to heart failure. There's also peri partum cardiomyopathy. This would be women who are around the time of pregnancy who can develop heart failure. And there's also congenital heart disease. So patients who were born with congenital heart defects and many of these patients are now living into adulthood. And some of these patients over time, whether they've had surgery, one surgery, multiple surgeries or never had surgery. We do find sometimes develop heart failure and need consideration for advanced surgical therapies for their heart failure. in terms of the symptoms, typically, heart failure will present with patients who have swelling in their legs or in their bellies, which is from fluid retention. Because as the heart becomes less and less able to pump blood in a forward manner, things back up and get congested so the lungs can congest. There can be shortness of breath and you can get swelling again in the legs or in the abdominal wall.

Erin Spain, MS [00:10:33] You mentioned different ways that heart failure can present. For some people, it's genetic. They're born with it. It's congenital, maybe something that happens during pregnancy. But in some individuals, heart failure could be prevented. Tell me about some of the ways that people can lower their risk of developing heart failure.

Arman Kilic, M.D. [00:10:51] Yeah, I mean, heart failure comes in so many different forms and each of them will have its own set of risk factors that honestly, I think the most important thing is to make sure you're plugged in with a health professional. And that's not just your primary care physician or a primary cardiologist, but at some point is the heart failure. Once it's identified that it exists and it's followed and you have follow up visits that are set up with either your primary care, your cardiology specialist. We do always emphasize that as the severity increases really do get plugged in with an advanced heart failure cardiologist early in the process. Advanced heart failure cardiologists are cardiologists by training, but they have subspecialty expertize and experience in treating patients specifically who have advanced heart failure. And they can do a lot of things that can prevent the progression of heart failure, including titrating medications, frequent follow ups, ordering the correct tests and getting you plugged in with the right other specialty or consulting services to make sure the entire body is taken care of. As you would imagine, as the heart fails, other organ systems can fail to, for example, the kidney, and you can go into renal failure or kidney failure over time. And so getting sort of comprehensive care, knowing that the primary problem is heart failure is very, very important. And I think the best way to do that is really to get plugged into the specialists pretty early on.

Erin Spain, MS [00:12:10] The technology continues to improve and change for these mechanical circulatory support devices. Tell me what has changed in recent years and what you're able to offer people now?

Arman Kilic, M.D. [00:12:20] I think this is actually a very exciting time for the ventricular assist device community. There have been parallel improvements both in the technology, so that's the actual devices. Currently, there's one commercially available device that is implanted throughout the country and throughout the world, and this is a device where the design is actually what's called the magnetically levitated pump design. So, what that entails is that there is very limited interaction of the patient's blood with the device. So, the compatibility of these devices with the patient are much, much better so that you don't get a lot of clots that form in the devices and so forth. And we're seeing that with much, much better outcomes now, where patients not only have better survival, but the complication profile is reduced, meaning the risk of stroke, pump failure or pump stoppage because of clots and so forth are much, much better with these newer devices. In addition to the devices and the technology, our management of patients has improved tremendously over the last few years. As a community, we've become much more comfortable of treating patients and managing patients who have ventricular assist devices. And as we build our collective experience in taking care of these patients and as we do studies on the research front, and we learn more and we identify risk factors and things in management that have an impact on outcomes, we're able to optimize our care much better, and we're seeing that directly translate into patient outcomes which are getting much, much better with each year that goes by.

Erin Spain, MS [00:13:47] There's also a new cardiogenic shock program here at MUSC Health for severe heart failure. You are leading this effort to create a statewide shock program. Tell me about this. First of all, tell me about cardiogenic shock and what this program aims to do.

Arman Kilic, M.D. [00:14:02] Cardiogenic shock is one of the most severe forms of heart failure. It typically is an acute process, meaning patients come in and they're very, very sick and they require being in the intensive care unit. It can again take multiple forms. The two most common settings where patients develop cardiogenic shock are either with acute heart attack or patients who have known heart failure, but then have sort of an acute on chronic decompensation. And those are the two populations typically where we see cardiogenic shock. Again, it is a very lethal disease. It's got a 50% mortality rate. And part of that is it's very difficult to diagnose and identify patients early who are in the shock process. Secondly, they require very hands on, very high level and complex decision making. Many of the times they will require very quick escalation of mechanical support to support their heart function, and that's to, again, provide blood flow to their vital organs, allow their heart to rest and so forth. And so this is a problem actually nationally where the outcomes have been very, very dismal for cardiogenic shock. And in this effort, there have been lots of programs that have been looked to develop what we call a hub and spoke model, which is, you know, you're really talking about central, highly specialized --- care hospitals that support multiple peripheral hospitals where if patients who are in cardiogenic shock come to a peripheral hospital, there's a means of communication and discussion of these patients and appropriate transfer to higher levels of care early in the process to optimize their odds of successful outcome. Also, many of the times these patients will require bridging or eventually being treated with another therapy like a heart transplant or a durable ventricular assist device. And so it's nice to have those patients transferred early to centers that can provide those therapies. In South Carolina, we're in a little bit of a unique geographic infrastructure in that MUSC is the only center in the state that performs heart transplants. And we're one of two centers that performs durable left ventricular assist device placement. So, for us, even if it's a quick phone call from a center to ask us, is this a patient a candidate for a transplant, for example? Or can you give us your opinion on how you would want to treat or support this patient? We're always looking to engage with the community and with other providers throughout the state and to provide whatever level of support is needed to manage individual patients or to manage patients, you know, in cardiogenic shock. And we've made a lot of progress, I would say, in the last year where we formalize this process, including a formalized patient management algorithm that's been agreed upon and really a multidisciplinary way by interventional cardiologist, cardiovascular intensivists, heart failure cardiologists, cardiac surgeons. And now as a service, what we offer to referring physicians into referring centers is a conference line where physicians can activate what we call a shock team. And what that entails is all of these various clinical providers in these various clinical domains get on the conference call very quickly within a few minutes and can provide a consensus opinion on each of these cardiogenic shock patients, including facilitating transfer if it's appropriate.

Erin Spain, MS [00:17:11] So this could be in the middle of the night. A center 200 miles away may call this line and you guys are ready to answer?

Arman Kilic, M.D. [00:17:18] 24/7. You know, as a multidisciplinary premiere, advanced heart failure group, again, our message that we want to send to both providers and clinicians across the state and throughout the region, but also to patients, is that we're here as a resource and we're here to really offer something to the patient. So if the patient has complex high end care or second opinions, things like that, we're always here to just help support whatever it is we can do to give patients, you know, their desired outcome. And that may be different for different patients or for different families. There may be different capabilities at various hospitals throughout the state. But as really the state's only heart transplant center, we are looking to support the community, support the state and really do whatever we can and bring our collective expertise across the various clinical domains to offer the most we can for South Carolinians and beyond.

Erin Spain, MS [00:18:09] What do you do to optimize your health and live well?

Arman Kilic, M.D. [00:18:12] I do think sort of disconnecting and doing some reflecting and easing your mind. And whether that's meditating, yoga or taking a walk and just disconnecting as much as you can, I think is very helpful and I certainly try to do some of those things. It ultimately, I think, translates into being able to perform at your highest level. And so I think those things are very, very important.

Erin Spain, MS [00:18:33] Well, thank you so much for being on the show today.

Arman Kilic, M.D. [00:18:35] Thank you.

Erin Spain, MS [00:18:40] For more information on this podcast, check out advance.muschealth.org.