Heart Care Takes a Multidisciplinary Village

MD-Update Q & A with Steven Heatherly, MD

Steven J. Heatherly, MD, PhD, FACC, is the system medical director for heart failure and pulmonary hypertension for Baptist Health’s Louisville Heart Failure and Pulmonary Hypertension Clinic.

LOUISVILLE
Steven J. Heatherly, MD, PhD, FACC, is the system medical director for heart failure and pulmonary hypertension for Baptist Health’s Louisville Heart Failure (HF) and Pulmonary Hypertension (PH) Clinic.

MDU Please tell us where you grew up, and your education and medical training.

I grew up in rural North Carolina. When I was four, I told my parents I wanted to be a doctor, but my path to medical school was not linear. My undergraduate degree is from the Honor’s College of Western Carolina University in Cullowhee, North Carolina. I was a biblical studies/religion major and I ended up with a PhD in psychology. That’s when I decided to go to medical school at Eastern Virginia Medical School. I did my internship and residency in internal medicine at Wake Forest University Baptist Medical Center in Winston-Salem. I stayed on for one year as assistant chief of medicine. I then entered into my cardiovascular diseases fellowship at Wake Forest, as well. I also picked up a master’s in philosophy, so I have a varied background.

MDU When did cardiology become your primary focus?

I liked cardiology when I was in medical school. Later, while in residency, I fell in love with the field. There is a lot of physics in cardiology, which I have always loved. But my real passion developed when I fell in love with two big diseases: pulmonary arterial hypertension and heart failure.

MDU What brought you to Baptist Health?

Baptist Health was my first position after I finished my fellowship. I was looking for a hospital that wanted to launch a pulmonary hypertension clinic. I first went to Madisonville, Kentucky and opened a PAH and HF clinic there. I recently transitioned to Louisville to be the system medical director, as well as staff our heart failure clinic and open our new PAH clinic here.

MDU What does a week in your professional life look like?

I keep a solid schedule. I have both clinical and administrative time, so I see patients in our heart failure and pulmonary hypertension clinic and I do procedures in the cardiac catheterization lab. I also read echocardiograms throughout my day. I have designated administrative time to oversee my division at our nine hospitals in Kentucky and Indiana. This can include significant time for meetings, including Zoom. I’ve been restricted because of COVID, but still able to visit each of our nine hospitals to assist with their heart failure programs. I am also the principal investigator for several randomized clinical heart failure trials, so I can often be in research meetings or doing data analysis.

MDU Describe your patient population: age, gender, presentations, treatments.

Heart failure is more common the older we become, so the average age of my patient is in their 60s. However, I see patients aged 18 plus. They include both females and males. Most of my patients have issues with fatigue, malaise, shortness of breath, and swelling. We have many prescription medications available for both HF and PAH. Some of my patients need implantable devices such as a special pacemaker known as “CRT-P,” and some need defibrillators, such as ICDs. Some of our patients also have an implantable pulmonary artery monitor (CardioMEMS). Some of my HF patients also need surgical procedures, such as CABG and valve replacement.

Some patients may need to consider LVAD/heart transplant. My patients with PAH need right heart catheterizations, often more than once. Some may also need to eventually consider lung transplantation.

MDU Kentucky is known for heart disease. How does the Baptist Heart Failure Clinic continue to innovate and address a common problem?

Kentucky has plenty of cardiovascular disease. At Baptist Health, we believe the best way to assist patients and their families is to focus on specialized areas for our patients. One example is the HF and PH clinic. One of the issues with both HF and PH is that the disease can enter into a flare state. Patients can suddenly have worsened breathing and swelling. We have same-day appointments for our patients, all with an eye toward preventing an ER visit or an admission. We can even offer them IV therapies in our clinic that is typically relegated to the ER. I like to think we meet our patients where they are.

We are also innovative as a health system because our nine hospitals currently participate in over 200 clinical trials, so we are literally contributing to the knowledge to help care for patients in Kentucky and southern Indiana. We also offer remote patient monitoring in our Heart Failure Clinic, so some of our patients are eligible to have Bluetooth and WiFi scales and monitors at home that monitor their vital signs. This information is conveyed directly to my office so we can monitor patients and improve their quality of life by helping them live at home, avoiding the ER and an inpatient hospital stay.

MDU What are some of the new treatment plans and procedures for treating heart disease, both medical and surgical?

We have very exciting options for patients with heart disease. More and more we are seeing increasingly minimally invasive approaches. As an example, we have a robust structural heart program at Baptist. Some patients with aortic stenosis can undergo TAVR, which is a minimally invasive bioprosthetic valve replacement. This procedure traditionally required open heart surgery. For patients with particular types of mitral regurgitation, our team also offer TMVR, which is transcatheter mitral valve repair, commonly called MitraCLIP. For patients with blood clots to the lungs, a pulmonary embolism, our interventional cardiology team, in select patients, can do catheter-directed thrombolysis, a catheter approach to addressing clots in the lungs. Baptist Health Louisville also has a robust mechanical circulatory support (MCS) program including ECMO, of which we are very proud. And, for some of our PAH patients with a particular form of PH known as “CTEPH,” which is PH from chronic blood clots to the lung, there is a surgical procedure available that can be curative for some patients known as a pulmonary thromboendarterectomy (PTE) There are very few places in the world, and very few places in the United States, that can offer this. I am proud to say we have recruited Dr. Mariano Camporrotondo, a cardiothoracic surgeon, who can perform this procedure and we able to offer this to Kentucky and surrounding states.

MDU Talk about the collaborative team approach at Baptist Health Heart Failure Clinic in Louisville.

Healthcare takes a village. No one physician or clinician can know it all. So, a multi-disciplinary approach is a necessity. Our HF patients, as an example, likely have a primary cardiologist, an electrophysiologist, and some of them will also need an interventional cardiologist/structural heart disease specialist. Many of them will need to see cardiothoracic surgery and participate in cardiac and pulmonary rehabilitation. They will depend on our medical assistants, nursing, case management, and social work. Our PAH patients will likely need to see sleep physicians and pulmonologists. Some of them also need rheumatologists. So, I treasure the ability to have an extremely talented and diverse healthcare team here to depend upon.

MDU Describe your interaction with patients and their family, particularly the initial visit. Tell us about a unique patient experience.

“At Baptist Health, we believe the best way to assist patients and their families is to focus on specialized areas for our patients.” – Steven Heatherly, MD

I always state up front that I often meet patients and their families on some of the worst days of their lives. HF and PH are scary diagnoses. I keep my initial appointments for one hour. And, I am typically in the room for that time, and often longer. I want to start with the patient and their family telling me what they know. I go through all of their medical records, pulling up images in the exam room. I want us all on the same page: how we got to this exact moment in time. I will then solicit a patient’s values and goals. Then, I work to make that happen. That includes discussing diagnostic testing, procedures, and possible treatments.

I have so many stories about unique patients and experiences, but I will summarize it by saying I am so proud of our HF team in the clinic. We recently started a charitable fund so we can assist some of our patients with their medical financial needs. We can use those to even send an Uber for an appointment! Recently, we had a patient — who is always on time — fail to show up. I had two people who work in my office actually leave to drive down the road and go check on her. It turns out she had lost her phone, so she could’t use the Uber we had arranged. These two wonderful humans gave her a ride to my office and we were able to complete her visit. And, I have to tell you, that isn’t unusual behavior — at all! — on the part of our clinic staff. It’s such an honor.

MDU What are the most common misconceptions among non-cardiologists and the heart disease patient population that you want to address?

Let’s start with pulmonary hypertension. The biggest misconception is that “there is nothing do,” or, that it is “hopeless.” These patients now have longer life spans than ever. We are fortunate to have several PAH-specific medications for these patients. There is also this idea that “not all PH patients need to be seen in a PH clinic.” I disagree. It is true that a lot of the times I will concur with someone’s else assessment and treatment strategy, but it is also true that national data indicates that up to 94% of the time a PAH-specialist will recommend additional testing/treatment, and one third of the time the patient will actually get a different diagnosis. For HF, about 10% of our patients will end up with AHF, advanced heart failure. And some of these patients will need to discuss LVADs and heart transplant. The misconception with these therapies is that they should not be discussed with some patients, or some individuals have errors in thinking about hard age cut offs and things of that nature. We have a lot to offer every single patient. Period.

MDU What’s on the horizon of cardiology and cardiac surgery?

One thing we are seeing nationally is moving in-patient care to the out-patient arena. In the next decade many, many things that now require hospitalization will likely be treated in the out-patient arena. This means that the hospital will be reserved for sicker and sicker patients. So, we have to continue churning out excellent cardiovascular physicians in our training programs. This trend is something we are helping with actively in the HF clinic with same-day appointments and remote monitoring. I think we will also see vast improvements in our LVAD technology. Right now, one of the biggest limiting issues with LVADs is the driveline and battery technology. It is a line that comes out of the abdomen and is prone to infection. That line is required to power the battery, but I am anxiously hopeful the battery technology will improve to the point where an LVAD can be 100% contained inside a patient’s chest and charge much like you can do now with a magnet and a smartphone.

MDU Are you currently involved in any clinical trials?

Yes, I am currently the principal investigator here for two randomized clinical trials: STEP-HFpEF and STEP-HFpEF DM. These trials are investigating a medication known as semaglutide in patients with HF. We are looking at several outcomes such as change in KCCG, body weight, laboratory values, and even some echo changes. Overall, my priority as the system medical director is to expand our HF and PAH research here in Louisville, so I think we can expect to see a vast increase in our research here.

MDU Describe your personal philosophy of care.

Training is intense. Wake Forest was an excellent proving ground, but it was challenging. I had a mentor who said, «We take care of patients; that’s what we do.” It was that idea of putting this other person in front of you before your desires, your sleepiness, your hunger. And, for me, it sums it up well for me. I, of course, want to be respectful, honest, open, and transparent, but at the end of the day I take care of patients and their families; that is what I do.