Sentara Master Series presents a live CardioMEMS™ implant procedure performed by Deepak Talreja, M.D. The CardioMEMS™ sensor is implanted in the pulmonary artery during a minimally invasive catheterization procedure. The placement of this device allows heart failure patients to take a daily pressure reading to monitor fluid buildup.
Good morning. Thank you all for logging on today during your lunch time for a live case of a cardio memes implant on a patient with diastolic heart failure. I think we have an exciting morning or afternoon almost here for you today in the room. We've got Dr Deepak Tell Regia and dr ahmed Bedier here at Sentara Virginia Beach General Hospital in Cath lab to patients who we've just brought and prepped and is on the table with the right IJ sheath in place. I'll introduce the members of our team. After first we have an opening and introduction from Dr Wayne. Old Wayne. Good morning. It's a pleasure to be with you today. Um I'm actually off site not in the lab at Sentara Heart Hospital. Um Deepak has chosen to present this case and actually do the case of cardi memes implant which we've done it sent terror since 2017. Um I am part of the advanced heart failure team at Sentara Heart Hospital where our clinic follows approximately 80 to 100 patients with cardio memes implants. Um Cardi Memes was actually the development of a implantable pulmonary artery sensor device which became popular and went to the FDA for approval in 2016 after the landmark article called the Champion Trial Which was a randomized study that looked at patients that whether or not constant monitoring of PA pressures could be used to improve re hospitalization rate. That study actually decreased rehospitalization rates by 28%. Therefore it became part of our guidelines for management of patients with um decompensating heart failure. It's approved for patients that have New York Heart Association class three heart failure and a patient who's been hospitalized within the last 12 months. This procedure is affable for both patients that have reduced left ventricular systolic function. In this case. This gentleman who has normal left ventricular systolic dysfunction are as normal left ventricular systolic function. So both for half half and half ref patients. This is utilized in so now we'll go back to the operating room where Deepak will tell us a little bit about the patient. Thank you so much wayne. So mr ce is a pleasant 82 year old gentleman. I've known him for about a decade. He has a history of valve disease. In 2020 he presented with increasing shortness of breath in the setting of a normal ejection fraction with mild coronary heart disease appropriate for guideline driven medical therapy and severe aortic valve stenosis. After a work up by our structural heart team we implanted a medtronic core valve and the aortic position with a significant improvement in his symptom Atala ji at that time. In addition to severe aortic valve stenosis, he had moderate mitral valve regurgitation. It was not severe enough to warrant an intervention and obviously at the time of the T. A. V. R. He was seen by both the mid atlantic cardio thoracic surgery group and our Sentara cardiology structural heart team and it was felt that he did not need a mitral valve intervention. That mitral valve disease many times after Tavern will improve in his case over the next year it got worse. And he ultimately went on to mitra clip procedure and has to mitra clips which have reduced his mitral regurgitation to the mild range. And then over the last six months he's developed progressive episodes of as you heard, N. Y. H. A. Three class heart failure with the lower extremity edema and disproportionate shortness of breath. He has mild underlying lung disease. He's very functional for his age. He's been a recreational pilot and flies old vintage airplanes up until relatively recently. He's given that up now but delightful. Gentlemen more recently with his heart failure he's had multiple echocardiograms and cath assessments. He has no new coronary disease. He does have a preserved ejection fraction last assessed at 65% with echo parameters consistent with significant diastolic dysfunction. Grade three by eco criteria. He's had three hospitalizations in the last 12 months. All with heart failure as the main precipitous um at each of the hospitalizations we've discussed cardio memes and each time we thought we would adjust medication therapy. He's currently on a beta blocker. He had developed some renal insufficiency and we had him initially on an A. R. B. Which we've stopped we tried him on an S. G. L. T. Two inhibitor. And because of side effects related to a recurrent valen itis that was ultimately stopped as well. That was obviously an exciting therapy to think about and eventually hopefully get him back on the A. R. B. We've considered mRHS and for now I have not had him on that as yet. Anything I've forgotten you would add from our review. Perfect, perfect recollection of the story and you know, giving us all the clinical details of this patient who fits the perfect candidate for this procedure. Can we also know his anti pro BnP you remember? So yes he's had multiple anti pro BMPs across admissions. The last one was during his admission which was november 12th and he was in the low thousands. Then he's been as high as 2000 and he gets as low as the few hundreds after aggressive diary sis which is kind of his resting outpatient level on his assessment today. He still has considerable shortness of breath his edema because we diaries him a bit was reduced. Let me take a moment and introduce some of the rest of our team in the room. Obviously a program like this. You see we have advanced heart failure. We have the community heart failure team involved together as well as general cardiology. We're gonna switch to the mobile mike with Amy. Thanks for uh shooting everyone. I'm gonna have you guys raise your hands as I say names so everyone can can identify the audience. We've got Judith Tolentino scrubbed in Audrey. Yeager is circulating in the room and in the back on the monitor, josh Dolinsky the cardamom uh team really involves a large spectrum you know it's great having a tremendous advanced heart failure team who advises as these patients get sicker especially with those low af patients that need consideration for vat and transplant in a patient like this, a lot of his cares in sort of the general community we have in hospital teams, Cindy furman and Karen Lawrence in the back there who see these patients monitor them while in the hospital, communicate with them, educate on them. Uh In the back next to them we have Joy Dodson, ELISA Petra Skus and I think Karen Rocker scrub next door. But the administrative team takes an active role in helping make sure we have the availability to do these procedures, take care of the patients before and afterwards. Um We have Dave Lindfors with Abbott and he and his team participate in the procedures by helping us check the device, educate the patients, get their first monitoring done here. I know the first day we did it, they actually went to the patient's home to get the last monitor check done late at night and then of course a tremendous outpatient team. All the cardiologist, a PPS and nurses throughout our office program. I'll call out specifically Jessica minor does a lot of the nursing checks on an outpatient basis and then R. A. P. P. Team uh chelsey Christensen. Uh jennifer Dreyer and um Kristin McElhaney are three amongst many that go through and on a weekly basis. Check these numbers, make calls to the patients to do interventions, check on their diet, their salt intake and everything else. So with that background there's a lot of people whose names I didn't have time to mention. I've tried to keep it brief but really this is dependent on a great team to do well. Wayne any comments or thoughts. You know the heart hospital has a huge program. This is the group that does it over here. Anything you'd add before we start swimming. Well just briefly we have a team of five nurse practitioners. So you know what we look at the patients is first we have to make sure that they are on guideline driven medical therapy. You have to make sure your patient is optimized. That's how the patients were enrolled in the trial. So if you have a patient with heart failure with reduced ejection fraction make sure that they are on optimal therapy with these agents. You know whether it could be an A. R. B. Arnie ace innovator beta blockers, uh Spironolactone and Grd two innovators. Once they're on G. D. M. T. You'll be surprised many of these patients. The ejection fraction just recovers although they may still remain symptomatic. Next thing to know is whether the patients have A. I. C. D. Or not because Champion trial and roll patients who had A. I. C. D. S. Especially those with heart failure and reduced ejection fraction. Moving on to have patients. I think this is one of my favorite procedure in these patients because The volume starts status is so sensitive. Um you diaries them and then they go into renal failure. You stop the diabetics and then they go into heart failure. So they have a very low margin and um you can see now we are doing the right heart cat the air pressure is 11. All right. So let's grab an ira here. He has known pulmonary hypertension as well has been seen by a pulmonary hypertension clinic but he has a combination of elevated ph pressures and also disproportionate elevated wedge pressures which have been confirmed at previous right heart cafs. So right atrial pressure. Are you guys getting numbers? You can see nice tv waves from the tricastin regurgitation there and that vegetation is pushing me back a little bit but I'll get into RV. No. And if you'll change scale for us consistent with the pulmonary hypertension. He's had R. V. S. P. S. As high as 77 here were a little lower than that comments or thoughts. A. d. p. 16 grab us one more RV. Now that the whip artifact is a little bit better. Perfect. It's important to track the your swan catheter because you know that your wire is probably going to track the same path when we deploy your al Qaeda memes device. Alright we're switching and getting a P. A pressure and we'll resize again and again consistent with previous findings of pulmonary hypertension. Okay And then we'll get a wedge. I think this catheter is going to want to wedge on the right side eventually will switch it over to the left. What are your thoughts about left versus right sided implants? So it's a good question you know? Um It's interesting that many times the catheter just flips into the left P. A. But when you go I. J. Most of the time it does go to the right P. A. It's indicated to deploy the device in the left P. A. But there have been instances where the anatomy is not suitable. We have deployed it in the right P. A. As well And I would add here. So it's interesting. His wedge pressure is coming out around what? 27? There's not significant v waves which fits with our last Echo on the absence of significant mitral regurgitation by I think this is really additive to me because honestly by exam I would have guessed a lower number today. His lower extremity edema is better than it's been in the past. Although he is continuing to complain of some shortness of breath. So I have to admit you know even having known him I've underappreciated how how much his wedge would be today on this. All right. I'm gonna use a. J. Wire to get us over to the other side here and we'll grab a P. A. Sat. So we have a a cardiac output measurement. Yes. So really interesting numbers. Uh peer pressures are read out 83 20 for me. No. 43. And wedges 27 kind of correlates with pia diastolic. This is important for us because that's how you know when you have your device readings it will give you a P. A. Systolic and diastolic and also mean pressures. It will not give you a wedge pressure. So it's important to know how the P. A diastolic correlates with and much pressure. 0.5 I mean uh so it's a little more sedation. He does have a history of a dye allergy. And we pre medicated him from that. He's obviously had a number of di exposures. So with the wire it floats itself nicely into the side we want to implant on. And so our next step of course, will be to take a picture and see where we want to put this device. There are different ways to float this catheter on the you know left P. A. This is the best method to just use a regular wire. Um You can use the device wire but then that wire, if it bends, you don't want it to entangle in the and the device. Alright, let's take a look and see if we're in a place. We're all happy with. Generally use 50 50 contrast. Wanna come a little higher up And then can we zoom into a 14" field and I don't remember if we made comments on the Audrey, Can you push the II towards us so I can see more of the of the left lung fields. Then we make comments about the valves. You can see the the previous hardware and this one is what I want. Can you rotate it in? Yeah, that's good. But Okay. Mr Yeah. Alrighty. Like it. So as you can see because of the significant permit hypertension. There is pruning of the vessels and you're not able to see A good 10 cm vessel to deploy. Another trick I do is I just inflate the balloon a little bit so that you can then see the larger vessels. Now you can see the other bigger arteries. I might need a little more contrast. All right, ready, Okay, let me use this first. Perfect. Now, you can see how the tree has lit up. Probably this one was going into some branches. I can pause here, let me go back again. And now you can see you want to choose the brand which is more medial. Another thing which helps is to go L. A. Card and it really eliminates other branches which are going towards the periphery. You want to switch us over to coddle and we'll take a picture. I'll see if I can get a little more selective. Too nice. Mhm. Just make sure. Yeah, that's really nice. Ready? Beautiful. You see this is an amazing example how you just go low and you can just avoid those branches which are going towards the lung right now. Now we know exactly where we are. We can either wire in this view or we can go to a P. I like this so much. I think that's why we're here. Both of those two branches that we see look actually pretty favorable to me. What what do you think as far which which one would you choose? I would use the one which is going straight down. Um And so we've got a platinum plus choir here we're gonna pass through our end hole of the swan catheter. And since this is the last few up it's kind of nice to have this right And then we've got a sticker marking our spot of where we want to go. So remember the loops of the device there 10. So you want the p. A vessel at least more than that so that it can accommodate the night in all loops of the sensor and we'll take a look at the sensor soon. Okay so that veered off to the right, let's see if I can get it down the straight line. We tend not to put a curve on this wire just because we don't want anything that can potentially hook on the device once it's in place. Beautiful. Thank you. So I think that's a pretty good spot so you can see it has taken that medial branch and we are now you know we're gonna work together to leave the wire in place and remove the swan. Now we'll flush this swan and keep it ready so that later we can use the same swan back in and take our measurements dr but you're happy with that spot? I think so too. That's nice and dr old. Can you hear us? Yes. Any any comments, thoughts or questions from anyone out there? I've got wire so far. Looks great. Are you happy with that spot? Yes. Looks wonderful. Now as we know that we are in the medial branch we can go A. P. Mhm. May be interesting to point out also deepak that we usually do not anti coagulate these patients that the procedures go so quickly. We usually do not anti coagulate. Just for members in the audience to know that. So just to compare our ap shot here you can see the probably the branch which is medial to the swan is the branch we have taken. So we're in a perfect spot to deploy. Maybe maybe when we actually deploy it we'll go back to that one shot. Just make sure we like this. And then when you mentioned the procedural anti coagulation, comments on the long term anti coagulation. So one of the write the recommendation is to give 30 days of Plavix after successful implant and we is if they're on other anti thrombin biotics such as kuma nin or ela quis. Uh Some of these patients obviously have atrial fibrillation are in this case perhaps some valvular heart disease. So those patients do not get Plavix so as long as they're on some anti thrombin biotic procedure or drug um but if if they are not uh then we do recommend Plavix for 30 days but just 30 days. Alright, just uh take a quick look at the sensor here. So one second we're gonna switch over to the handheld camera so you can see the device, we'll give it one second and then you can make your comments good. Perfect. As you can see this is the sensor with the 99 loops here. The length of this area is 4.5 centimeters. So when you deploy the device you can exactly know where you are at with your wire. Um the width of the devices around two millimeters and this particular silicon area of the device which has the induct er coil. If you can tilt it a little bit Judith um the copper like thing here, that's the conductor coil and it's embedded in a formidable seal so that there is no air or gas leak and then there's a capacitor on this side which transmits and makes it a complete system. And the delivery system itself is hydra filic, that's why you have to submerge it in normal saline And you kind of ruined it for 30 seconds to two minutes so that the hydrophobic coating gets activated. The length of the delivery system itself is 120 cm so that you have to just use appropriate wire delivery system so that you don't run out of. And you made the comment. I think it's worth from memory. Again, one of the beauties here is with no battery. This device doesn't require replacement. All the charging is through inductive charging exterior early. You can see this is the wire poor and this is the delivery locking cable and AMY. Did you get a picture? Yeah. And this is the device itself. Once it's been liberated from the catheter with the angel wings that hold it in place. Perfect. Alright, Judith has gotten the device ready. We're gonna because again, we're light on anti coagulation. We're gonna keep flushing this sheet as we have been doing since we put it in. That's a great point. Right? When the device goes in, make sure your sheet is flushed so that it doesn't carry any traumas or clutch one of the device. We're gonna stay on Amy's camera until we've got the device up to the neck and then we'll go ahead and switch back to the large screen monitor. Perfect. Alright. It's important to buy monitor the higher position as the device goes through the valve of the sheet? That's when the via tends to come back. Can you make a comment on the sheet size we have in and just share that. So we have an 11 French shot sheet there it's a cook sheet. Um we used a regular micro puncture access street and devices and as you can see now the device is about to cross the trike a spit valve. It's so important to keep the device in the inner side of the delivery catheter so that it doesn't get entangled in the sub valvular parties. You can see how nicely tracking I'd like to add. Sometimes these patients have I. C. D. Leads and I feel like I know the other view better as far as our end point. Do you think about switching L. O. Watch your feet? Our angle on that last one was Elio 21 and 22 of coddle. Alright let's just we're gonna play the last image one more time. So what do you think about just past that bifurcation area? Perfect. Yeah so it will be close to one of the clips. Yeah that's a good landmark wayne. Are you happy with that spot too next to the clip? Just past that bifurcation. Yes and just perfect. Deepak. Deepak, can you hear me? This case was nice. This was nice because you didn't have any I. C. D. Leads or patients? Sometimes you have to be very careful as you trans verse those leads with the device but this is very nicely done. Thank you. Now one thing I'm noticing and I think Dave I hear you saying this in the background um Judith, hold this for me. You see how the additional end of that catheter is straightness. Um advanced wire for me so I can come back just a little bit. And so I don't think that's actually the distal end of the delivery catheter. I think it has that been from the tension on it. That was a good observation to watch for the will come down and around. A little more Judith has that fixed Judith give me a little backward traction on it. Um Come back up. Yeah, I think it went down really well. You can see the four radio opaque markers on the device. Right? That was a little this is a little higher currently than I had originally intended to implant. But because of the way that discipline of the wire is behaving. What do you guys think about that spot? I think that's a good spot. I think it's just one of the branches what you were seeing before is your balloon kind of trapped in the ratification of the pulmonary arteries. We're still in a good sized branch. Yeah. You think take it or you think going a little deeper? I think you should be okay. Yeah, just around there. All right. I think we like it. So amy can we go back to the monitor? Doctor body is going to deploy this while I hold it in position. Uh We'll go back to uh this, right? So as you can see there's this locking screw here. We got basketball. So we're gonna switch the hand camera so you can see what we're doing at the table. And then we'll show the device on the screen afterwards. Gotcha. So as you can see the blue unlocking screw, you do counterclockwise three twists and the device as you can see on the screen gets released. Now let's flip to the screen so they can see the devices jumped off and you see beautifully the outline of it and it's facing us, which is lovely. We've got the two dots above and to box below. As as you had mentioned earlier, just floor save save. Save that for us. Any comments on that. I think that's a great position, isn't it? It's beautiful. Now, the next step is we'll keep the wire fixed well slightly advance the catheter to make sure it's fully disengaged from the device. We don't want to drag the device back. So I've advanced it just a little bit there now gently come back first, a little bit with the catheter. And in this case because there's that bend in the wire, I'm actually gonna bring the wire back a little bit. So I'm using the catheter to straighten that piece. Right? I'm gonna bring us a little bit back further and then we'll straighten that all the way actually, if I hold there, can you can you bring this back? Yeah. Yeah. All right. See if you can come back into the catheter with that as you can see, we got the wire inside the delivery system so that it doesn't loop onto the device. Perfect, thank you. And now we're gonna do is what I like to do is leave the wire up so that it's easy to get the swan in place again. We've created some bends in that wire judy, you're gonna leave that there. I would like to keep the wire away from the device so there's no chance of it pulling back and here we often create some ftp as you're seeing but we're coming back together, we're almost out with the catheter and then we'll just take the swan up. You see that in addition to the valve apparatus we've put in before we now have the cardamom sitting there. Beautiful. I've got wire. Alright. Now the hard part's done now, it's getting some signals and calibrating Without all the commentary, we probably would have been uh 15 minutes right wayne any any comments, thoughts or any any anything from the audience. Nothing from the audience. Now, at this point in time you can actually take the wire out and just float your swan as typically, I mean, you could either choose to leave it there, which is helpful to get the swan back up. But this was a pretty easy case to right heart cath. So at this point in time, operators could just take the wire out. I'm being lazy and just leaving it there to track over, but you're right. Mhm. Got it there judy. Yeah. The key point at this time is just to keep the wire away from the the uh Alright, let's take the wire out. Perfect. I'll take the balloon up on the swan and we're gonna hook up our buyer tip is intact. So the whole wire came out. That's good news. And as you can see from the angiograms and were initially worried that the vessel looked larger than the device. But actually it was branching right at that spot. And you can see absolutely no movement of the device. It's pretty nicely uh you know the 19 all loops have you know, kept the device in place. So we've got our P. A pressure now and then we'll switch to the hand mike. What we're gonna do is show you were putting the transmission system under the patient. It's like a tennis racket, we often say, so that we can lock the device to the signal and then we'll show you how the transmission on the screen looks exactly like what the device is giving us wayne. And um it, can I ask you guys uh your thoughts, you've seen the numbers here, The wedge pressure was 27. He's symptomatic in terms of shortness of breath but it is better than it usually is when he's admitted with N. Y. H. A. For failure. One of the other things we have to think about is what next target to set initially. And so I'll be curious to hear your guys thoughts as we as we get some numbers from the device Right in the mean it's 50. It's a good question. So we generally like our patients to be as you've Olympic as they could be so that you can always start with a good baseline if they come de compensated for the procedure it becomes really hard um to you know use a baseline pressure. Let me let me actually get amy to show that this is just such a beautiful transmission. So quickly right now you can see on the monitoring screen the blue tracing is RP A. To doctor buddies point. And then you see we're getting the device locked, you can make some comments on that as you can see it's exactly mirrors what's happening on the monitor screen here and that's exactly what you're also seeing on the Cardamom system. It does more than 2000 measurements per minute to give you the actual number as opposed to our monitor which the Cath lab system does around 1 50 to 200 measurements. So that's how sensitive the fidelity system is. And generally in Cath lab you could see a lot of interference because of E. K. G. Cables C arms. So we tend to move it away when we're calibrating the system while we're while we're doing the calibration to put you guys back on the spot wayne. And and how do you guys choose your thresholds now for follow up for long term monitoring. So as we know that this patient had a veg of at least 27 provided that his kidney numbers is created in his his baseline. The best he looks the best at this stage. Generally give plus minus five. So I would set his range with let's say he has a P. A diastolic now of 24. I would set his range between 20 to 30 of P. A. D. And then start from there. Obviously these are moving targets. So as he responds to medications or with the dilator therapy as an outpatient, you can always readdress and rearrange your PhD. But right now, for this particular case, I would set a PhD of 20 target PhD of pulmonary artery diastolic pressure of 20 to 30 millimeters of mercury. Yeah, I agree with um it uh this this gentleman has moderate to severe pulmonary hypertension. So he has sort of group to um so he's got a mixed picture. Um so with that you're never gonna get his wedge only at 12. Um so I think um it is spot on about a good target for him. I love it. All right, judy 3.7. Thank you. Okay. Perfect. Alright. We've got what we need. We've calibrated. We've chosen our targets. Now we'll get the swan out and then I'd like to give some of our team in the back of a chance. I'm gonna pass over my mic. Let's take the balloon down. We're far enough back. I'm happy to pull we'll get the sheath out in our calf holding area. You two talk for a second. I'm gonna ask these guys to speak a couple of comments about the wires. You can use any organ eight wire. You can also use a stiff coronary wire like mailman if you want. Um you can use a steel core wire. Um V 18 wire. Generally be 18 wires. The chip can be a little bit more abrasive or stiff. Um But I think you know still for our platinum employees are really good virus for this case. I will definitely recommend elio coddle view. It really gives some clarity where your virus going. Your buyer position is so that you can deploy the device appropriately regarding arrhythmias patients. Obviously those who have CRT. D. Devices, be careful not to dislodge their um LV lead because some of the swans they tend to go to the coronary sinus. Another thing to remember is keep the device on the inner perimeter of the wire when inner surface of the wire when you're trying to deploy the device that just keeps it away from the sub valvular operatives um If we can move on part is the easy piece of this. The next part now is we have high quality data coming in on a regular basis from his home. And so I'm now Cindy furman who really from our onset of the program has done a lot of this along with Karen and the team here next steps and what we do and follow up and absolutely comments on that. Thanks Deepak. This is just an example of how this team works together as a team uh to make the success of this patient. So so up front so what we do after implant is certainly we educate our patient on how to use their home device and monitoring our next step of course is to make sure they have follow up adequate follow up directly into the clinic with our advanced practitioners. So they'll be meeting uh mr s. You will be meeting with our patient uh providers in about a week or two. Uh From there we're going to continuously monitor His readings from home uh first intensely about for the 1st 30 days just to make sure we have a good beat on how his readings are and where his average should be. Uh from that point we meet routinely uh to make sure that their goals are correct and established well um and then we just take space with the patient, that's what we try to do. We try to connect with our patients and their families and make sure that they're there up to date with what's going on and and certainly making sure they know that we've got adequate care behind the scenes and just give an example of that. We have two patients upstairs now, one came in with new onset a fib you keep feeding us the numbers every day, Jessica Chelsea Kristin jen are checking patients on an outpatient basis several times a week and then we have alarm parameters set where if a patient goes out of whack and you can imagine every holiday there's a bunch of those coming up. Dr has prepared some slides, weighing anything else from you before. DR talks through some slides. Yeah. I think we've talked about the indications. I just briefly want to talk about people that maybe this does not apply to. The first point is this is an outpatient procedure. Uh These are not the right patients to put in and when they come in acutely be compensated, it really is important that patients are discharged and they come back for this procedure. So I can't overemphasize that point the most. It's also not a good procedure to put in patients that are on dialysis because you really need some leverage to be able to diaries patients and adjust their medications. And And so then in the original study that the champion trial really you had to have a G. F. R. Above 25 or 30 in order to qualify for the study. So Another patient population that this perhaps will not work for is the super beast. Uh there's a chest circumference size of 165 cm. Uh if it's always important to measure their circumference of the chest because obviously the receiver has to communicate and talk to the transmitter. So those are just some things to think about what this technology is not meant for. Fantastic. Thank you for the a great comment weighing about the chest circumference and sometimes a CT scan without contrast of the chest can help. Also, it's important to measure uh chest circumference more than 165. Right, so um just as a historical perspective, these sensors were developed for actually abdominal aneurysm. It was difficult to monitor district patients. So um the sensors were deployed in the abdominal aneurysm and then interestingly, you know, someone thought that okay, let's deployed in pulmonary arteries. So, and I think 2014, the company cardamom device this with Georgia tech And as you know that you know, the talked about the champion trial, you can see the all cause readmissions and 30 day readmissions were reduced substantially? 48-57%. One important thing to notice also is the frequency of heart failure therapy change what was happening in the treatment group. Is there substantial changes in the diuretic regimen in the A. R. B. S. Beta blocker therapy and even Alessa Ron Antagonists. As you can see there were 638 changes in the treatment group as opposed to 500 in the control group, it really allows you to proactively guide therapy in these patients. Also you can see that there is substantial peer pressure reductions from baseline. So patients who were worse, who had the mean peer pressure more than 35, just like our case today, they had substantial reduction which is the green graph you can see. And those who had intermediate pressure reduction, intermediate peer pressures between 25-35. They also had significant reductions in their peer pressures from the day. Of course home reading. And this led to guidelines um quantify or qualify. The device adds class to be indication which was not there. Before that this year's update on the heart filling guidelines had put um arguments as class two B recommendation for preventing readmission. Um just to know why this is important because we want to be proactive and we have to be able to action when we see these numbers. Right? And that's what the device allows us because weight gain symptoms as you can see is pretty late. When someone gets into heart failure. You can see around 20 days before they get admitted to the hospital, they start having elevations in filling pressures and that's exactly what the device will allow us to do in this particular patient where we can just quickly see the intra thoracic impotence changes um and then act on it way before he would come to us with weight gain and other heart failure symptoms. Um This is just a quick summary of the device. You have already seen the sensor. Um the second row here shows the actual electronic system which the patient goes home with. This is the cardamom pillow. They will have to lay on to send their numbers every day in the morning. And then the merlin dot net is the web database where Cindy is gonna log in to look at these numbers and make changes just to quickly again go over the device. It's 1 20 centimeters in length and the actual system as you can see, it's 4.5 centimeter and it's just the actual sensory size of a dime. Um It has this inductive coil which is attached to a capacitor, it really creates a specific resonant frequency as the blood pressure flows. This frequency is catched by the electrical um a measuring system wirelessly and that gives us the actual peer pressure. And this is a perfect example which in one of my patients, as you can see 24th for thanksgiving. Within two days you can see the peer pressure's going up the red and the blue lines are the peer pressures. And we quickly called her, she also noticed that and she took diuretics resulting in lowering of the peer pressures. And when I showed her this graph, she was just amazed how she was being tracked and this was a good learning experience for her that you know how diet has a big impact on her health. And you can use these graphs and these numbers to educate them as well. So um you know in summary uh we had some troubleshooting advice is if you haven't symbolized device you may have to snare it. You have to be very careful when you retrieve the wire because then you will have to snare the wire if you leave a piece of wire. We talked about deployment in the right way, if the P. S. I. S. Is not appropriate on the left. We had instances where the device symbolized on the right P. A. And we are getting perfect numbers. So yes, you can deploy in the P. A branch and I would love to get any questions from the audience um if that's possible, if anybody has any questions wayne. Do you have any comments? No, I actually have access to the chat box and I don't see any ongoing questions um in the chat box but I think that's uh a very good um a summary. Um and I think for future technology we're anxious to give the patient, you know right now, the patient sort of relies on our clinic and staff to call them. But I think of evolving technologies as industry progresses with this technology is to try to have the patient just like you pointed out on your example on thanksgiving day, if the patient was able to see that in real time, even without a phone call or from the clinic, I think that's a wonderful future technology that that is exciting that uh have it and other companies are working on to give the patient the power of rescuing themselves. And also, you know, it also gives them positive reinforcement of what foods to eat, what to stay away from in real time. Um, and you know, I'm sure you have patients and as well as I that you know, do adjust their diuretics according to how they feel. And if we could give them one more mechanism that they could, could actually see their p a pressures to to modulate that great comments. Well, I'd like to uh conclude the session. Thank you all so much for participating and tuning in this will be available offline as well. I'd like to say thank you to dr old and dr barrier for coming and being part of this and commentating and then thank you to the Cath lab team at Center Virginia's General Hospital and the staff here for around arranging the schedule around this. And then thank you too, Amy Ross and Michael Evelyn enjoy Dodson for all the work to get the electronics working, getting the transmission going and look forward to more of these in the future. Everyone have a great day