Dr. Arnold:
This is LiveWell Talk On...Structural Cardiology. I'm Dr. Dustin Arnold, chief Medical Officer at UnityPoint Health - St. Luke's Hospital. Returning to the award-winning podcast today is Dr. Richard Kettlekamp, medical director for St. Luke's Heart Care Services, to discuss what is structural cardiology, procedures performed here at St. Luke's, as well as the future of structural cardiology and cardiology services in general. Dr. Kettlekamp, welcome back.
Dr. Kettlekamp:
Thanks for having me.
Dr. Arnold:
You know, you've been on a couple times. Has your life changed?
Dr. Kettlekamp:
Same old grind.
Dr. Arnold:
Really?
Dr. Kettlekamp:
No, you know, it keeps changing, the world of cardiology. There's always something new, doing new things in the mitral space. We've got tri-clip coming and we could talk about all those things. But there's a lot of new things on the horizon.
Dr. Arnold:
Structural cardiology, if you didn't know anything about it, you could infer a lot. So what is structural cardiology?
Dr. Kettlekamp:
Well, it implies there's some structural problem with the heart and that often involves the valves. The valves are these one-way doors that let blood go one direction, and there's a problem with one of them. And so the first place that we did these non-invasive structural procedures was replacing the aortic valve. So something that many people have heard about, transcutaneous aortic valve replacement or TAVR. And that's kind of where this was sort of born. But we could also plug holes in the heart. We can treat mitral valve disease. You know, there's a number of things that we can do that are actually sort of structural problems with the heart.
Dr. Arnold:
We had one of your colleagues on, Dr. Bansal, and we talked about just cardiology in general and valve disease, heart disease, you know, arterial disease, et cetera.
Dr. Kettlekamp:
Right.
Dr. Arnold:
I was kind of surprised of the incidence of valvular disease actually is not going down. You would think with more and more people on the planet going through their childhood with penicillin or access to penicillin.
Dr. Kettlekamp:
Sure.
Dr. Arnold:
There would be less rheumatic fever, less rheumatic heart disease. But he was telling us that no, not really, that it's actually going up.
Dr. Kettlekamp:
Yeah, if you think about the incidence of valvular disease being from, you know, rheumatic valvular disease, it's pretty low. Now, if you lived in India, you know, the incidence of rheumatic valve disease is huge. And so a lot of times, a few years ago you would go to India to learn how to do balloon mitral valve commissurotomy and things.
Dr. Arnold:
Is that because rheumatic—
Dr. Kettlekamp:
Because of no access to penicillins and you know, basically a third world country. Whereas, you know, in the United States it's been eradicated. You had an episode of strep throat, you get antibiotics. So you don't have to suffer from this. Now there's an occasion where you see—
Dr. Arnold:
I can remember a board exam question for one of the times I've sat for it. I can't remember, maybe the first or the 10 year mark, you know how it goes, it all blends together. But it was a pregnant Eskimo with hemoptysis. Okay so, you know it's mitral valve disease, right?
Dr. Kettlekamp:
Sure.
Dr. Arnold:
You know, because they had pulmonary hypertension from valvular disease they grew up indigenous and didn't have access to penicillin. You know, so it's kind of that classic you think about. But yeah, you guys used to go to India to—
Dr. Kettlekamp:
To learn how to do mitral valve commissurotomies, because the mitral valve disease is so prevalent there.
Dr. Arnold:
Wow, I didn't know that. Have you ever been to India?
Dr. Kettlekamp:
I have not.
Dr. Arnold:
Yeah, me neither. That's kind of on my bucket list. I'd like to go there once.
Dr. Kettlekamp:
Yeah. My fellowship mate went to India to do just that. And he came back and we were in echo conference and he's next to me and he has these terrible rigors.
Dr. Arnold:
Oh gosh. What'd he get, malaria?
Dr. Kettlekamp:
He got malaria. Yeah, so we did a peripheral smear. So it was educational for all of us, because you never see malaria in the United States either.
Dr. Arnold:
No. Well, we had a case of malaria at Iowa Methodist in Des Moines that came over from Broadlawns. And I'll never forget this because this is back pen and paper, you know, right? This is late nineties. And the Broadlawns family practice resident had written, I was going through his orders and I was admitting into to the intensive care unit at Methodist, and one of those nursing instructions was "kill all mosquitoes in room."
Dr. Kettlekamp:
Okay.
Dr. Arnold:
Which I thought was pretty funny.
Dr. Kettlekamp:
That's awesome.
Dr. Arnold:
So we've kind of implied with our in the weeds conversation there, that it requires some extra training. What extra training does it require to be a structural cardiologist?
Dr. Kettlekamp:
Well, there's fellowships.
Dr. Arnold:
So you do your general cardiology.
Dr. Kettlekamp:
Right.
Dr. Arnold:
And then you go on to subspecialize, which I paid a complement to our cardiology group here. I think even prior to joining UnityPoint, even before when UnityPoint was still Iowa Health System, I think your group did a good job of saying, you know what, specialization is going to be the future here. We can't all be interventionalists, we can't all be the echo gurus. We're going to need to divide and conquer. And I think you guys were really about five years ahead of the wave that followed. So it's not unusual now. We did a podcast on inpatient cardiology and how we try to become more efficient with our time. But tell us about, just kind of take through how I would become a structural cardiologist.
Dr. Kettlekamp:
Well, you know, I mean the whole process of med school after college, and then residency in internal medicine. And then you do general cardiology, which is a three year residency or fellowship. And then you sub-specialize in interventional cardiology. So then you do, you know, coronary vascular intervention. And then after that, it's a one or two year fellowship in structural training. So, you know, what is that, 17 years down the road after high school. So it's a long haul. A lot of specialized training. Some of this was young enough that structural cardiology came about, you know, during my life as a cardiologist. So a lot of this that I've learned, I've done on the job.
Dr. Arnold:
Yeah.
Dr. Kettlekamp:
And so that's different. But, you know, there are structural programs out there and those are relatively new and kind of novel things.
Dr. Arnold:
Right. But like everything else, they'll probably become established and accredited as time goes on.
Dr. Kettlekamp:
A little bit more commonplace.
Dr. Arnold:
I think right now cardiology is where—I mean I've observed this in gastroenterology in my career—where it's just this explosion of technology that comes out of the sea. And it goes from nothing new to everything's new.
Dr. Kettlekamp:
Right.
Dr. Arnold:
And I think cardiology's riding that wave right now, particularly structural physiology.
Dr. Kettlekamp:
Right. It is, it truly is. You know, everything's becoming less invasive. You know, if you can avoid open heart surgery, people want to. There's still a lot of necessary open heart procedures, but then there are a lot of patients, a big population of patients, who just aren't surgical candidates. And that's where TAVR, aortic valve intervention, was born. There are a lot of people who have severe aortic valve stenosis and they don't express symptoms until they're 88. And, you know, you're not an ideal, typically, not an ideal surgical candidate at 88 years of age. And so those patients were just treated medically, and we know that the downstream is that those patients are going to die of the disease. And so TAVR came along, much less invasive approach to put a new valve in. And not surprisingly when they compared aortic valve replacement in the early days, percutaneously by a catheter, compared to medical therapy, the valve replacement blew them out of the water.
Dr. Arnold:
Have they studied valve replacement via open heart surgery versus TAVR? I mean, what's the comparison there?
Dr. Kettlekamp:
They have. So the way that this has sort of evolved was it started out in the non-operative patient as many technologies do. And then they decided, well, we'll take the high risk surgical patients and we'll compare those patients to surgery. And it turned out that TAVR kind of had some equivalency. And then they looked at moderate risk patients, you know, people who had a STS score of less than six who were moderate risk in the surgical arena. And they compared the two. And it turned out that the TAVR patients have done just as well, if not better. And then the low risk patients, so these are the people you'd think would do best with surgery. And they do, they do very well with surgery. But it turns out that the TAVR actually has superiority in terms of outcome for low-risk patients needing valve replacement. Now, the challenge of course, is a lot of low-risk patients are young and you can't put a fully prosthetic valve in with a catheter. It has to be a bioprosthetic valve, and there's pluses and minuses to both approaches. But the plastic and metal valve, the prosthetic valve potentially lasts forever. So if you're—
Dr. Arnold:
Are they to the point, and I know this is not the age group that you typically treat, but you hear about these children that have some sort of valve disease that they have to have several surgeries because they grow, right?
Dr. Kettlekamp:
Right.
Dr. Arnold:
I mean, are we going to get to a point where we'll just pop in a TAVR, then okay now we'll put in their permanent one.
Dr. Kettlekamp:
Probably not, in the sense that a TAVR valve can't be explanted.
Dr. Arnold:
Oh, okay.
Dr. Kettlekamp:
Yeah. So you put it in and you know what you're going to put in another valve inside of that valve. And so that's kind of a future that we face. We put in a TAVR valve and if a patient outlives that valve replacement, which can happen, I mean, if you have a sort of young healthy 75 year old who gets a valve replacement, that valve eventually is going to fail that person. We would argue, 10 to 15 years down the road, but then that same patient's 90 and now needs another valve because their prosthetic valve has failed. We would just put another valve inside of that one and sort of make a valve sandwich.
Dr. Arnold:
A valve sandwich.
Dr. Kettlekamp:
Yeah, it works pretty well.
Dr. Arnold:
Not what the Earl of Sandwich had in mind probably, but that will work. The expansion in the heart, which did have a Super Bowl ad.
Dr. Kettlekamp:
Right. That's pretty impressive.
Dr. Arnold:
It was a good commercial. So tell us about the expansion and what that is going to bring to the community.
Dr. Kettlekamp:
Yeah, it's a big commitment by UnityPoint Health, you know, to really solidify our service lines. You know, 25 million dollar capital investment in EP, so electrophysiology. And that's the first phase of this process.
Dr. Arnold:
We've had Dr. Lee on the podcast.
Dr. Kettlekamp:
Oh great. Yep. So I'm sure your listeners know about that, so that's kind of the first—
Dr. Arnold:
He'll probably be rated higher than the one with you, but that's okay.
Dr. Kettlekamp:
Oh, we know that.
Dr. Arnold:
Go on, I didn't even mean to break your concentration there. Sorry about that.
Dr. Kettlekamp:
We're not going into this. Kind of hurts, but it's okay. So the second EP lab, which is something that's sorely needed because we have a really busy electrophysiology service, so that'll be great. The second phase then will be vascular labs on the fifth floor, and we'll be moving our non-invasive therapies, echo and, you know, nuclear and stress testing to a different floor. But it'll all be consolidated in one area. And then vascular will move up to the fifth floor where Dr. Kray, Dr. Lawrence, myself, and Dr. Karrowni will be doing vascular procedures.
Dr. Arnold:
Just from a healthcare industry, young people perspective, I mean, I can't say this enough, there are so many career opportunities in healthcare right now that are just going to continue to grow. Whether you're an ultrasound tech, an echo tech, a certified surgical assistant, cath lab personnel, it's not always doctors and nurses. You know, there's a lot of other—it's a team.
Dr. Kettlekamp:
Sure.
Dr. Arnold:
And you can just feel that growth that's going to be there. You know, so it is an exciting time for young people to be entering the profession. And you don't have to have 17 years of training, you can have hands on, day-to-day significant contribution to the patient care with a lot less time.
Dr. Kettlekamp:
Right, for sure. Sonography being the classic example. Radiographers. Nursing, you know, a lot of people think nursing, you're going to go to a floor and take care of patients. But, you know, it's an exciting opportunity in the cath lab.
Dr. Arnold:
Yeah, the laterality and the horizontal potential for someone with a master's in nursing is very wide and very long.
Dr. Kettlekamp:
You bet.
Dr. Arnold:
Me and you, we just move long seeing patients and are just a cog in the wheel.
Dr. Kettlekamp:
That's right.
Dr. Arnold:
Well Dick, thanks for stopping by again. This once again, this is Dr. Kettlekamp joining me to discuss structural cardiology. He's the medical director for St. Luke's Heart Care Services. To learn more visit UnityPoint.org/heartcare.
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