Straight to the Heart—Through the Wrist: Transradial Cardiac Catheterizations Explained

In this episode of our podcast DocTalk, host Debra Schindler sits down with MedStar Health interventional cardiologist Dr. John Wang, director of the Cardiac Catheterization Labs at MedStar Union Memorial Hospital and MedStar Franklin Square Medical Center in Baltimore, to explore how cardiac catheterizations have evolved, and why the transradial approach (through the wrist) is transforming catheterization procedures.

Traditionally performed through the femoral artery in the groin, cardiac caths are increasingly going in through the wrist, offering: 

·       Faster recovery
 Fewer complications
 Greater patient comfort
 Same-day discharge for many patients

Dr. Wang explains:

• What symptoms may lead to a cardiac cath
• When the procedure is performed in emergencies (like heart attacks) vs. scheduled care
• Why national cardiology guidelines recommend the transradial approach
• What patients should ask their doctors before undergoing the procedure

If you or a loved one may need a heart cath, this episode will help you understand your options, and why the accessing the heart through the wrist is a better approach.

Learn more about interventional cardiology at MedStarHealth.org/MHVI 

To comment on this podcast, or suggest a topic for another episode send us an email: DocTalk@medstar.net

For more episodes of MedStar Health DocTalk, go to medstarhealth.org/doctalk.

Transcript

Speaker: 0:01

- Comprehensive, relevant and insightful conversations about health and medicine happen here. When MedStar Health DocTalk, these are real conversations with physician experts from around the largest healthcare system in the Maryland DC region. If you're looking for more information on cardiac catheterizations, this is your podcast. Because these important procedures have evolved so much through the years, and not everyone is caught up with the changes, which is interesting when you consider this fun fact. In 1929, a young German physician, Werner Forssmann, performed the very first human cardiac cath on himself. He inserted a catheter into a vein in his arm and guided it into his heart under x-ray. His supervisors were horrified at the time, but this bold act earned him a share of the 1956 Nobel Prize in medicine. Since then, cardiac catheterizations have become a standard procedure for physicians to get a direct detailed look at the heart and its blood vessels performed through the femoral artery in the groin. But it seems Dr. Forssmann had it right the first time. Accessing the heart through the wrist has transformed diagnostics and treatment for cardiac patients. We're going to learn more about transradial cardiac catheterizations with Dr. John Wang, who is truly a pioneer in interventional cardiac procedures performed through the wrist. He's the director of the Cardiac catheterization labs at MedStar Union Memorial Hospital and MedStar Franklin Square Medical Center in Baltimore. I'm your host, Debra Schindler. Welcome to Doc Talk Dr. Wang. - Debra, thanks for having me. - So when a patient comes to the cardiac cath lab, is it usually an emergency situation? Why does someone come in need of a cardiac catheterization? - Well, it can be an emergency. The most common emergency that brings people to the cath lab that would require a heart catheterization is a heart attack. Sometimes you've heard people refer to these as STEMIs, and these are a type of heart attack where the blood vessel is acutely 100% blocked with a blood clot. People traditionally have classic symptoms like chest pain and elephant sitting on their chest and are oftentimes quite sick. - Some of the symptoms that you might have people coming in, let's go through the list. - Sure. The classic one is chest pain and that chest pain or pressure or tightness can radiate to people's jaws. They can also have neck pain or teeth pain, and it can even radiate to the back. But not everybody has chest pain. You can also just have shortness of breath, and sometimes people only have nausea and are what we call diaphoretic, which is cold and clammy and sweaty. So that's what makes heart attacks such a deadly disease is that it doesn't always present with classic symptoms. And this occurs more commonly to not present as classic symptoms in women and in patients with diabetes. - And not all of these cases that come in are emergent cases. Some of them are diagnostic or scheduled. Tell me about those. - Right. Other than the emergent cases when people are having heart attacks, the vast majority of cases we do are elective and those are scheduled cases. And there are many different reasons why people have heart catheterizations. So common ones include having some symptoms when they, when they exert themselves, and you've heard of CT calcium scans, and these are very common scans now being ordered by internist and cardiologists. And when people have an abnormal calcium score, that raises concerns because calcium in the wall of the blood vessel is certainly associated with narrowing of the coronary arteries. Another common reason that brings people to the cath lab are positive stress tests. Again, usually patients have symptoms or they have a strong family history and they are being screened with a stress test. And if the stress test shows a certain area, the heart does not get enough blood flow. They're oftentimes referred for heart catheterization. But then there's another whole host of many different reasons, including heart valve disease. So in order to work up patients with heart valve disease, from aortic valves to mitral valves, and even the tricuspid valve, patients are oftentimes sent for a right and a left heart catheterization, which is a catheterization that looks to make sure they don't have any blockages in the blood vessels, but also one where they're measuring the pressures in the heart. And then of course, congestive heart failure. And this is an ever-growing population of patients. And there are many patients that have difficulty breathing and have been diagnosed with heart failure. And it comes in two broad categories, what's called preserved ejection fraction heart failure or heart failure with preserved ejection fraction where the heart is still strong in beating normally and it's actually too strong and not able to relax and fill properly. And then there's something called heart failure with reduced ejection fraction. And that's when patients have a cardiomyopathy, which is just a fancy way of saying the heart doesn't beat well and it's not strong. And because of that, they are having fluid back up into their lungs and having heart failure symptoms, and they can all sometimes get weight gain and swung in their legs as well. - So sometimes your patients may get other tests done elsewhere such as an echocardiogram or some other kind of cardiac testing screenings, and then they come into the cath lab for further diagnosis? - Correct. And again, the two main reasons are to one, to do a coronary angiogram, and that is to see if they have any blockages in the blood vessels that feed the heart. And if they do in very severe cases, those patients may need to have open heart surgery or bypass surgery to fix it. However, the vast majority patients with blockages in their coronary arteries can be treated with these little metal scaffold called stents that prop open the blood vessel. It's all done through the wrist. And then if the blockages are not severe enough and they're moderate or they have no blockages, then those patients we treat with medications. And those are really medicines like cholesterol lowering medicines and maybe baby aspirin. And these are things to help ensure that the blockages stay moderate and don't progress to more severe ones. - Do you take a baby aspirin every day? - No. I think baby taking baby aspirin is something that, believe it or not, is not completely benign. And it's definitely a discussion that one should have with their cardiologist because over a lifetime, it really depends on your risk profile and whether or not you have coronary disease. And although it doesn't seem like a big deal to take a baby aspirin, if you think about the decades that you would be on it, it certainly is a small increase in your bleeding risk. So if you've had gastrointestinal bleeding or other types of bleeding, it's not insignificant. But that's something that although most people think is fairly benign, it's definitely worth the conversation with your cardiologist and it's individualized based on your risk profile. - Good to know. Because if I thought it was gonna keep me outta your lab, I would take one every day. Okay. So first off, let's talk about what the standard treatment is. As I mentioned in the intro about the femoral approach, which has been the standard treatment for decades, right? Compared to this transradial or through the wrist approach. - Right. So heart catheterizations traditionally have been done through the femoral artery, which is a large artery in the groin area, and it's a very easy artery to access, and the procedure can usually be done very safely from there. This has some risks, though. There is about a 1% chance of a vascular complication. 1% doesn't sound like a lot, 99% chance it's gonna go well. But when it doesn't go well, it may not just be a bruise or bleeding that requires a blood transfusion, but people have even died from bleeding complications when it's done from the femoral approach. When I was training up in Boston in 2003 and 2004, we were doing radial heart catheterizations. However, the technology in terms of the wristbands that actually hold pressure when you're done as well as the catheters and the sheaths, that technology hadn't really evolved to the point where patients truly benefited from that approach. - Let let, let's back up a minute because I don't think everybody hearing this will have a complete and full understanding of even what a cardiac catheterization is or what happens. So let's start with e femoral. - Sure. - You do something. Yes. You have a catheter. - Go ahead. Yes. So what we do is we numb up the skin and we insert a small needle that allows us to put a large IV that we call a sheath. It's like the IV you get when you go to the hospital in your arm, but it's larger. And through this IV or sheath in the groin, in the femoral artery, we're actually able to pass catheters up into the heart. And what we do is we actually inject dye into the left coronary artery that lets us see the two major branches that come off of the left main artery, the left anterior dis he artery and circumflex. Then we use a different catheter to inject dye into the right coronary artery so that it comprises the three major blood vessels that feed the heart. Now of course, if you've had open heart surgery and bypass surgery by a heart surgeon, we also have specific catheters that look in those blood vessels too. And what we do by injecting the dye is we are looking to see if there are any narrowings in those blood vessels. And if there are, those are the patients that have significant ones that we treat with stents that prop open those blockages. So again, the traditional procedures have been done through the groin. And in 2010 we started really going from the radial approach. And it was certainly a challenge because the best analogy for converting from femoral to radial approach is probably much akin to what it's like to have a patient who's had a stroke that has to learn how to walk again, something walking that we don't even think about. For most of us, you just put one foot in front of the other and you do it and literally effortlessly. But if you watch patients that have had a stroke and they have to learn how to walk again, and they have to be able to balance and to think about their motions and how much effort takes, that's a very good analogy for what it's like for operators that have done femoral cases for years to convert and learn how to do radial heart catheterizations. It's much more challenging. Getting the catheter or the sheath into the radial artery, which is much smaller than the femoral artery can take quite a bit of learning curve. Then putting those catheters into the left coronary artery and the right coronary artery is completely different in how we do it from the arm versus the femoral artery. And finally, one has to learn how to insert stents into those blood vessels safely from the radial approach. So it's quite a commitment from the physicians that learn how to do this. And there are still many physicians that decided not to convert to the radial approach. To give you an idea, when we started this process, 2010, less than 20 to 25% of the stent procedures in America were done from the radial approach. Now we're about 40 to maybe 45% in America. And to put this in perspective, at MedStar Union More hospital, our PCI rate, or the percent of patients that get a stent from the radial approach is just about 90%. So a quite a high number. And it's not just doing it from the wrist versus the groin. There's really very good reasons to do this. The first is it's about patient comfort. So number one, when you talk to patients who've had a heart catheterization from the groin, and when we're done, they have this sheath in the groin after that's removed either with a little collagen plug or a stitch, which would be a closure device, or it's taken out and someone has held pressure to make sure it stops bleeding. Patients have to lay flat for several hours afterwards. And if you talk to patients, they say that's the worst part of the whole procedure laying flat afterwards. Especially if you have back problems, you can't sit up, you can't eat, you can't go to the bathroom. So these are, - And when you say several hours we're talking - Yeah, three - Or four, maybe - More. Yeah. Sometimes if it bleeds, it could be four to six and sometimes even longer depending on the size of the sheath that's in the groin. Hmm. So patient comfort is a big deal. So let's compare that to the radial approach. You have it from the wrist. When we're done, we put what's called a transradial band on there, which is a comfortable wristband with a little air diaphragm that we blow up some air that holds pressure and patients are actually able to sit up. They don't have to lay flat. And not only can they sit up, they can stand up and stand up and go to the bathroom. Then they can also sit up and eat with their other hands. So it's, it really transforms the whole hard catheterization experience. So we talked about patient comfort. The next really important piece, probably more important than even the comfort of the patient is the patient's safety. So if you think about a 1% major complication rate from the femoral approach, that number from the radial approach is essentially zero - Zero complications from going in through the wrist. - Nothing is exactly zero. - Yeah. - Yeah. But it's as close to zero as possible. - Okay. That's amazing. Compared to - 1%. - 1%. - Okay. So when you think about doing thousands of procedures in a cath lab a year, all of a sudden that's a big savings and complication rates. Right. Again, remember I mentioned earlier on patients have even died from a heart catheterization. Okay. Because of vascular complications. Why is it so safe? It's so safe because the radio artery is so superficial and it's so easy to control the bleeding that even if patients do have some bleeding or oozing from that area, you can easily apply a couple fingers of pressure and control that bleeding. - You don't need to put a stitch in the wrist to close it up. - No, never. No, absolutely not. And so it really is a much safer procedure. And when we review our complication rates on a monthly basis in our performance improvement meetings, our vascular complication rates from these radial procedures is routinely zero 0%. And that is a number we've grown accustomed to because so many of our procedures are from the radial approach, like I said, over 90%. And when we do have a vascular complication, it's no surprise it happens to be in one of those patients where it was from the femoral approach. - Oh, interesting. - So yes, the second main benefit for patients is really the safety aspect of it. - What about infection? Is there a risk of infection with the femoral or the risk? - There's always the, a small risk of infection anytime you break the skin to do a procedure, even from getting an IV in. But the infection rate is exceedingly, exceedingly low from a heart catheterization. The times that we have seen infections from a heart catheterization have been in patients that have diabetes and are somewhat obese. And we put a closure device in the femoral approach, which is a little collagen plug, and sometimes that collagen plug can get infected. It is extremely rare, but that is the only time we really have any infection from a heart catheterization. Otherwise it's essentially non-issue. - Does that stay there, that collagen collagen's closed? - No, it gets absorbed by the body within a few weeks. Okay. And disappears. Yeah. - Okay. So for the, the wrist approach, is the patient asleep? - Yeah, it's a good question. So the heart catheterizations have really evolved from a decade or two ago. And when we do a radial heart catheterization, patients get very, very light sedation. It's a little tiny twilight, but they're able to talk and they're able to take a deep breath if we need them to. And we put a little bit of lidocaine into the radio artery right before where we're gonna stick it with our needle, a very small needle. And it looks very much like that wheel that's raised. If you've ever had a PPD TB test under your skin, it's a tiny little wheel of lidocaine and it numbs the skin. And the procedure, believe it or not, to take pictures of the blood vessels and see how well the heart squeezes if we don't do a stent procedure, can take five to six minutes and patients, - That's very quick. - Yeah. Patients are always surprised. They're like, that's it, that's all there is to it. And I always joke with them that, yeah, this is, you know, easier than going to the dentist to get your teeth cleaned. So you are opening certainly - Faster a vessel in six minutes? - No, we're, we're able to put the catheter into the wrist and put our catheters up into the heart and take pictures of the blood vessels. Okay. And make sure that there are or are not any blockages. If we have to insert a stent, it usually takes a few minutes longer. And depending on the complexity of the procedure, it can be another five, 10 minutes, or it could be a half an hour longer. It really depends. And it depends on how many blockages we're fixing too. - So inserting that stent is the same as if you were inserting it through the femoral artery? It's - Correct. - Positioning it the - Same. Yep. It's the same. And I think the biggest challenge for physicians when they convert from the femoral to the radial approach is the first challenge is becoming very good at radial access in order to get the radio artery again. And remember I said it's a much smaller artery. The second challenge is being able to understand the differences in the anatomy. So you can choose the right catheters to get really good pictures of the heart, and if need to put a stent in, in a very efficient manner. And again, that just takes experience. - It seems like a shorter distance though, from the wrist to the heart than the femoral opening to the heart. - Yeah, actually, you know what, not a significant shorter distance. Okay. If you put your arm by your side where your radio arteries is very close and distance to where your femoral artery is. So still a little ways away, but it, it's, it's got other advantages beyond - That. When you put it that way. Mine is probably a longer distance. I have very long arms. - Yeah. - Does the patient feel any pain when they're, when you're sliding the catheter - Through the room? No, you know, patients are always surprised by this heart catheterizations when we're actually putting the catheters into the body and taking our pictures. Patients don't feel it. And I try and explain to them that there's no nerves on the inside of these blood vessels. Imagine how distracting that would be if you could feel blood flowing through your blood vessels. Oh, good point. Right. And yes, we feel a little, maybe distention sometimes with gas, with food going through our GI system, but you know, we don't feel food transiting between our stomach to our small intestines, to our large intestines. So again, a lot of this is the way we've evolved. There are no nerves on, on the inside of these blood vessels. And we use that to our advantage. Right. So once we are in with our catheters, you know, patients don't feel a thing and they're, they're surprised and they constantly say at the end of the procedure, I didn't even realize you started yet. I thought we were just talking. And I said, no, no, no, we're done the procedure. - Right. They're talking through the procedure. - Yeah, exactly. - That's amazing. Isn't that not distracting for you? You've probably done it so many times. - Yeah, no, it's not distracting. It's actually quite nice. And I think it really is great to put patients at ease. - Now, a friend of mine had called me once. He was very concerned about having to go into a hospital for a scheduled cardiac cath procedure to get some diagnostics done. It was scheduled through the femoral artery. But he was worried because that weekend his grandchild was due and he wasn't gonna be able to travel. And I was surprised because as you said, we've been doing it since 2010. - Yeah. - That they were still even considering doing e femoral. He wasn't high risk or anything. - Patients should be their, they're their best advocate. And when you go get a procedure, it's important to ask some questions. And you know, I think one that would be important to ask is that do the doctors at this facility, are they comfortable with doing it from the wrist versus the groin? It really is beneficial for patients to have it done from the radial approach. And the other advantage is that when we put a stent procedure in from the wrist, that patient about a third to about half of those patients, if it's not a complicated procedure and they didn't have a heart attack that brought 'em into the hospital emergently, those patients go home the same day. And the advantage of that is, you know, I don't have to tell patients that the advantages of being able to go home and sleep in your own bed versus having to stay in the hospital overnight. But if you have the procedure done from the groin, from the femoral artery, and you have a stent placed, those patients we still routinely keep overnight. And because rarely they can have bleeding complications at nighttime. And so we keep them overnight. So the radial approach has allowed us to send home up to about 50% of our stent procedure patients the same day, which has been a tremendous patient pleaser to be able to go home and sleep in your own bed. - Well, it sure was for this friend of mine, because I told him about the transradial approach. He didn't know it existed and it wasn't offered to him. I was just surprised by that because I thought it was a more widely used technique for cardiac catheterizations and maybe not everywhere. - Right. I think it's interesting because in a program like ours where it really is the norm, I think people that have only worked here just assume this is the way it is at other facilities, but really it's not. And again, the national average for doing PCI or stent procedures from the wrist is about 40 to 50%. So to, to be up at 90% is really unique. - What should patients ask for then, if they know that they have to get a, a cardiac procedure? Should, should they ask? And how would you want to be asked - About this? Yeah, I mean, I think I, I think if patients are gonna have a heart catheterization procedure, they should find out a little about their doctor and how many have they done, how long have they done it for? Do they have experience from the radial approach? And if there's published data on the outcomes for that particular hospital in terms of their complications rate, these are all things that patients could look into. But most patients, I have to tell you, Deb, they do what their doctor recommends. Right. I always say patients should really be their own advocates. And when you're talking about Ashley undergoing a procedure, it's worth doing a little research and find out, does this institution, and particularly the doctor you're going to, do they do the radial heart catheterization? Do they have a lot of experience? What are their outcomes? Et cetera. And those are good questions to start with. - I think too that it's important to mention, don't just take our word for it. Right. The American College of Cardiology, the American Heart Association, and the Society for Cardiovascular Angiography and interventions explicitly recommend TRA or transradial access as the preferred arterial access for coronary procedures. So that's pretty affirming for this. So my friend, he comes out of the procedure, any patient comes out of a transradial procedure, as you pointed out, they, they don't have to lay flat for hours on end. They can then go into what we call a transradial lounge. - Yeah. - And what a great concept. - I tell you, it's, you know, if you go to a regular prep and recovery room after a femoral heart catheterization, it's like any under recovery room. It looks like a post-anesthesia care unit. There are beds, sometimes they're individual rooms, sometimes they're just separated by curtains. But nonetheless, it's designed for patients to lay flat and for hours. But we took a different approach and we actually developed what's called the radial lounge. And there are eight bays in this lounge. And there are actually no beds in each of the bays. Each of the bays has a armchair that reclines, because patients don't have to lay flat after their procedure. And so on one half of this lounge, you have these eight bays and you're on a, a heart monitor, and there are nurses there monitoring you. But in about an hour when that wristband comes off, you can go to the second half of this radio lounge where there is a seating area and a large tv. There's another area where you can sit and read and charge your devices. There is a small cafe where patients can get drinks and some snacks in a self-serve atmosphere. And then even a small room with a computer that later on the doctors can come and review your films with you. So it's really transformed the whole experience of a heart catheterization and taken a lot of the fear away. And I often describe the radio lounge a lot, like the waiting room for when you get your car serviced more so than actually a traditional hospital - Or an airport. An airport lounge. Exactly. I've seen people sitting in there watching tv. Right. Or they're with their fa multiple members of their family. Right. And they're sitting in jeans, - Right. - Reading or having a coffee. Yeah, it's, it's very nice. - It's a, it's really a great experience for them. - What's the recovery like once they go home and they resume their normal activity? - Yeah, it really depends on what the indication for the heart catheterization. So for a heart attack patient, they may have to take it easy for a few days. When we say take it easy, we mean no heavy exertion, but we don't mean sit around and do nothing. In general, the recovery after a radial heart catheterization is no heavy lifting with that wrist for a day or two. Not a lot of flexion in an extension. So no tennis, no golf, just no heavy lifting. And I always tell patients, I don't want you to not move your wrist. I don't want you to mobilize it, but just pretend like you sprained it, you know? And and trying to don't - Go easy. Go easy. Yeah, - Go easy for a day or two. But then after that it should be totally back to normal. - What if they have a stent? - Same when they have the stent? Again, the precautions we have for the radio access is very similar. But again, I would advise patients to discuss with their physicians and there will be very clear discharge instructions on what their activities can be, depending on the indication for their heart catheterization. - In an emergency case, what's the most, I guess, dramatic case that you've managed in the cardiac cath lab? - Well, I mean - That you've treated trans radially. - Yeah. I mean now we, we really do all of our STEMI patients or heart attacks through the radial approach. And I'm glad you brought out that recommendation by our societies that have really recommended this. But there's one area in particular where there's clear mortality benefit to patients if we go from the radial approach, and that's in these heart attack patients. And the reason for that is that during STEMIs or heart attacks, when the vessel is a hundred percent blocked and those emergent procedures, patients are very, very sick. And the blood vessels blocked a hundred percent with a blood clot. And in addition to opening it with a stent, oftentimes we have to put patients on very powerful blood thinners. And as you can imagine, the more blood thinners you're on, the greater your chance of bleeding, especially if you're going from a femoral approach. Right. So by going from the radial approach, you've virtually eliminated that access site bleeding. Not to say that patients don't have other causes of bleeding from gastrointestinal causes, et cetera, but really the major bleeding risk that occurs with the heart catheterization is from the access site. So when we do heart attack patients from the radial approach, there have been many studies now that show that those patients compared to ones done from a femoral approach die less. Okay. It's a safer procedure for them. Any heart attack patient, we really try our very best to do from the radial approach. - So I have to ask the question, who would not be a candidate for a transradial? And then you'd have to go through that femoral artery. - Yeah, I mean that happens, right? Because remember we said about 90% are done through the wrist, so that means there's 10% that aren't. So the radio artery is one of the two arteries in the forearm that we can go into. On the other side is the ulnar artery. Most patients have two arms, so four arteries that we can try and put our catheters in. So if you go into the same artery multiple times for multiple different procedures, sometimes it gets more challenging to get into that artery. And patients also sometimes have a one artery that's smaller than the other. So in some patients, the ulnar artery is larger than the radial, but in most patients, the radial artery's larger than the ulnar. So usually if we fail in one radial artery on the right arm, we will go to the left arm. And if we fail in that, we can try the ulnar arteries. And if we fail in those, then we can go into the femoral artery. Patients who've had their artery taken out for open heart surgery and had the radio artery used as a conduit for a bypass. Obviously we can't go in those patients' radio arteries and patients who have a fistula in their arm that use that fistula for hemodialysis. Those patients, of course, we also don't go into their arms to do the heart catheterizations. When you take all of that into account and patients with very, very small radio arteries or that have a lot of problems with Ray Raynauds or spasm in their vasculature of their hands, and those patients, we would try and avoid it. But when you look at our numbers, we're talking, less than 10% are unable to be done from the radio approach, - Which - Is really remarkable. - So what is your final advice for patients or potential patients or people who are taking care of their parents and loved ones? - I say be your, be your own best advocate and ask questions and make sure that this is being offered at the place where you decide to have your heart catheterization. And one word of advice I always tell physicians, learning about the radial approach is that at the end of the day, the ultimate goal is to have a successful procedure. And so you never wanna let the approach compromise your final result. If you are going from the radial approach, and it's very challenging, you cannot let that cloud your decision whether or not to actually fix a blockage or not, and how to fix the blockage. So like I said, what I say to those physicians is that the most important thing is to have a successful procedure. And with the continued commitment to the radial approach, the success rate continues to improve, which is incredibly rewarding and also benefits our patients the most - Perfectly said. Thank you, Dr. Wang. Thanks, Debra. Thank you for, for making that commitment 15 years ago. Of - Course. Yeah. Thanks. - We've been talking with Dr. John Wang at MedStar Union Memorial Hospital. Thank you so much for sharing your expertise with us here on DOC Talk. For more information about interventional cardiology at MedStar Health, go to MedStar health.org/MHVI. That's MedStar Heart and Vascular Institute. If you would like to comment on this podcast or recommend a topic for another episode of Doc Talk, send an email to Doc talk@medstar.net.