Heart to Heart with Anna

Telemedicine and Patients with Congenital Heart Defects

March 26, 2019 Dr. Ami Bhatt Season 13 Episode 13
Heart to Heart with Anna
Telemedicine and Patients with Congenital Heart Defects
Heart to Heart with Anna
Telemedicine and Patients with Congenital Heart Defects
Mar 26, 2019 Season 13 Episode 13
Dr. Ami Bhatt

Dr. Ami Bhatt is the featured Guest on this episode of Heart to Heart with Anna.  Dr. Ami Bhatt is an active clinical cardiologist, clinical investigator, and educator. She has developed a robust multidisciplinary curriculum at Mass General to provide requisite ACHD education to cardiovascular fellows. Dr. Bhatt is dedicated to patient advocacy groups including the AHA and Adult Congenital Heart Association and empowering individuals with CHD to lead full and productive lives.

In this episode, Anna talks with Dr. Bhatt about becoming an adult congenital cardiologist specializing in the care of adults with CHDs, why she developed a telemedicine program for her patients and where she believes the future of medicine is headed. You won't want to miss this show which discusses an up-and-coming trend to prevent Heart Warriors from being lost to follow-up care.

Support the show (https://www.patreon.com/HearttoHeart)

Show Notes Transcript

Dr. Ami Bhatt is the featured Guest on this episode of Heart to Heart with Anna.  Dr. Ami Bhatt is an active clinical cardiologist, clinical investigator, and educator. She has developed a robust multidisciplinary curriculum at Mass General to provide requisite ACHD education to cardiovascular fellows. Dr. Bhatt is dedicated to patient advocacy groups including the AHA and Adult Congenital Heart Association and empowering individuals with CHD to lead full and productive lives.

In this episode, Anna talks with Dr. Bhatt about becoming an adult congenital cardiologist specializing in the care of adults with CHDs, why she developed a telemedicine program for her patients and where she believes the future of medicine is headed. You won't want to miss this show which discusses an up-and-coming trend to prevent Heart Warriors from being lost to follow-up care.

Support the show (https://www.patreon.com/HearttoHeart)

spk_0:   0:00

spk_1:   0:00
lot of us have done that relationship building and so it is scary and there's a lot more to learn. But the same time we're also learning to build fields and congenital cardiology.

spk_3:   0:17
Welcome to heart to heart With Anna I am Anna Dworsky and a host of your program. Today's episode is called Telemedicine and patients with congenital heart Defects. Dr. Amoeba is an active clinical cardiologist, clinical investigator and educator. She has developed a robust multi disciplinary curriculum at Mass General to provide requisite is the HD education to cardiovascular fellows. Dr. Baden is dedicated to patient advocacy groups, including the American Heart Association, an adult congenital heart association, and empowering individuals with CHD to lead full and productive lives. She works in conjunction with the heart failure, transplant arrhythmia and Val programs. Oh Bijan Genetics and Pediatrics Doctor Bought offers tele visits to care for individuals with a C H D. Who lived far from Boston or are limited in their ability to make in person

spk_0:   1:14
visits. At the Mass General CHD help the wellness program, patients receive education about CHD and after a sclerotic cardiovascular disease, primary prevention education in segment where we're going to talk to Dr Bought about becoming, ah, cardiologists specialising in the care of adults with congenital heart disease. Segment two will focus on why she developed to telemedicine program for her patients. And then the final segment will discuss where she believes the future of medicine is headed. Welcome to hard to hurt within a doctor bought.

spk_1:   1:46
Thank you so much for having me.

spk_0:   1:49
I'm so excited to have you on the program. I've had the pleasure of listening to some of your presentations in person in Boston and then later in Texas. So this is really exciting for me. Let's go ahead and start by having you tell us why you decided to become a cardiologists.

spk_1:   2:08
Well, it's actually little funny adult congenital heart disease is what made me decide to be a cardiologists. I was a medical resident and we were on the pediatric cardiology rotation, and we were called one day to the adult cardiology floor for an emergency. And that doesn't happen often. Pediatricians being called to the adult floor for some reason,

spk_0:   2:28

spk_1:   2:29
And it was because there was an adult with congenital heart disease who was having some complications, and the adult cardiologists at that time did not know as much about the congenital disease men. So they called our team. And in my mind we were in a perfect the shape flock formation, white coat flapping in the breeze. And we arrived on the floor and help this young 40 year old with tetralogy of fellow who had landed in adult cardiology with a pediatric condition but with adult complications. And that was the first time that I saw how important it was that those two fields would merge in the future. And so really, I like to think of that day as the day that I started on the rest of my of course.

spk_0:   3:11
Wow. And that was pretty early in your training, Dead

spk_1:   3:16
it waas! And as I moved through it's interesting. I feel like the field of adult congenital heart disease grew along with me, and people who had had surgeries in the 19 seventies were now coming of age. Those in the 19 eighties were, you know, coming of age, with even different surgeries bringing different complications. And as I went through medical on residency, the numbers of these patients really started to increase dramatically, and I was seeing them on every rotation. I trained in medicine and pediatrics, and it didn't matter which hospital I was in. I was always seeing them wherever I went.

spk_0:   3:51
Is it not amazing? And it's so gratifying for me to hear you say this because my son was born in the 19 nineties, and the biggest question at that time was, will he survive to become an adult? And now we're seeing so many adults. It doesn't even seem like it's as much a concern as it used to be.

spk_1:   4:13
Absolutely. I think it's been great to be able to see them. One of the concerns that we do have actually doesn't have to do with the disease and our success per se, but our success in getting them from when their kids actually seeing them when they're adults because you know, when you're younger, you're mom brings the n. You're getting mean. But as they emerge into the workforce or college age or, you know just being old enough to say, you know hey, Mom will either go myself for I don't want to go. We really have a problem with loss to follow up of young people who were there not being here is adults. If you counted the numbers of adults with congenital heart disease, we should be seeing it's upwards of 11 and 1/4 1,000,000 right now in the United States, where is actually if you look in the major adult congenital heart disease centers? It's less than 100,000 that air

spk_0:   5:03
followed in HK

spk_1:   5:04
ordinary centers. Wow, it's probably more than that that followed in the general cardiology population in the country, and that gives me solace that there are probably people getting care. But it reminds us the networks of care are important so that you can talk to people who have trained in it. You can get the advice you need on how to care for them in the communities where they live,

spk_0:   5:25
right? Well, my son is an adult now, and as soon as he turned 18 he decided he didn't need me anymore of his visits, which was really upsetting for B. But I I was gratified for him to say to me, Mom, you've been preparing me all my life to be able to do this. You have to trust me and he's been fairly good. He's pretty good about when he comes back from his visit. He'll share any paperwork he was given and helped give me a synopsis of what happened. But he was starting to feel so good that he decided he didn't need to go for a full year. And I was having yet panic attacks because I don't do you know in you to do well, you know

spk_1:   6:08
exactly well, So it's so interesting to the things you just said. So the first is it. Turns out there's actually researching some of our good friends have done in this that shows that parents and physicians, we seem to think that the child's attachment to seeing us when we're Children is very strong. And so we're not sure how to help them graduate sometimes, right? Well, you know, the 14 year old patient needs me and will continue to need me. But if he moved two hours away and there's an adult congenital cardiologists there, the kid is actually pretty comfortable transitioning. And it's interesting. When we asked surveys, the parent says, Oh, no, they're very attached to their original cardiologists and the doctor says, Well, they've known me for years. They're very attached to me. And it turns out that half of the kids say, actually, no, I could probably pushed another doctor. I'd be

spk_0:   7:02
okay. It's important

spk_1:   7:05
for us to empower them, devoid that opinion, and,

spk_0:   7:10
you know,

spk_1:   7:10
sometimes they will voice an opinion. I feel very comfortable with this person. Then we have to help them establish the relationship with the new doctor. And I don't just mean graduating from pediatric cardiology to adult congenital. I also mean moving across the country. If you look at young people today, they don't stay in the same town in the same city, oftentimes as often as we used to an older decades. And so as

spk_0:   7:31

spk_1:   7:31
traveling, we need to be able to readily transition them, even as adults from one adult, congenital cardiologists to the next and help them feel empowered and help them bond with that new physician as quickly and easily as possible. So I think you're right. You know, he says, you got him ready for it, and kudos to you. But we all need to get them all ready for

spk_3:   7:51
that and help them feel empowered for their own care.

spk_4:   7:55
Take this hot industry. We're offering us a mechanical hot, and he said, now that I've had enough to give it to someone who would be My father promised me a golden dressed twirled it, held my hand and asked me where I wanted to go. Whatever stripe for conflict that we experienced in our long career together was always healed by humor. Heart

spk_5:   8:16
to heart With Michael Please join us every Thursday at noon, Eastern as we talked with people from around the world who have experienced those most difficult moments

spk_3:   8:31
forever by the Baby Blue Sound collective. I think what I love so much about this CD is that some of the songs were inspired by the patient's many listeners will understand many of the different songs and what they've been inspired. Our new album will be available on iTunes. Amazon dot com. Spotify. I love the fact that the proceeds from this CD are actually going to help those with congenital heart defects join music home Tonight forever.

spk_2:   9:08
You are listening to heart to heart with Anna. If you have a question or comment that you would like a dress to show police in an email to Anna Dworsky at Anna at heart to heart with anna dot com. That's Anna at heart to heart with anna dot com now back to heart to heart with

spk_0:   9:27
Before the break, we were talking with doctor bought about the importance of adults with congenital heart disease and even our teens early teens, as a matter of fact becoming comfortable with taking charge of their own care. So now I have a question for you doctor bought. Why is it that we lose so many of our patients to follow up care?

spk_1:   9:51
That's a great question. I think there's several factors to it, and we've done a lot of patient focus groups and, you know, my patients can tell you I'm always asking them questions about this. But I think the most important thing for finding is one, as you mentioned before, when people feel well, they're not sure that they need to go see care. And that's even true with people going to their primary care doctor.

spk_0:   10:10

spk_1:   10:10
in midlife I think the second thing is they've

spk_0:   10:14
been through a

spk_1:   10:15
lot. And so any individual who had chronic disease, you do wonder if the other shoe gonna drop when you go to your doctor's office and there's a little bit of anxiety and there's fear. And sometimes there's almost what we would call PTSD, especially something we're studying, whether or not that actually happens in adult control heart disease but memories of what it was like to be ill that make you very nervous about coming back into the hospital system. And so I think that's another important facet. And then there's logistics. If you're a 20 or 30 something and you're either working or in school, you don't live in the big city next to the tertiary care center that provides a dull Condell hard to be care, then it's actually quite complicated for you to get in. A lot of my patients have kids who they have to pick up from school. You know, there's a lot of life that happens, and what we want to dio is empower people to be able to maintain all that life and yet somehow make it a priority or fit into their schedule. The fact that routine congenital heart disease care is really important to help them stay healthy, and it's reframing that from a scary aspect of health care to an empowering aspect of health care. But I really do think logistics, some anxiety, fear PTSD. And then other times just I'm healthy and I don't want to go find anything else out.

spk_0:   11:40
Right? Right. You know that fear anxiety hole of those issues that you just talked about that happens with us parents, too. Especially parents like me who thought we had healthy Children throughout our entire pregnancy. And it wasn't until after our child was born that we were told that our child had something serious room with them and almost died. I mean, even for me, I always feel like I'm waiting for that other shoe to drop a swell. And I try to be vigilant. Which is why it scares me when Alex skips his cardiology appointments. Because I want I am to continue to do well. And I think what you were talking about with the logistics that ties in very nicely to that vibe you know, episode that I had a chance to see. And my web master will put a link to that on the website. So all of you can see it as well. And in that Vimeo presentation you were talking about telemedicine. This is something that I feel is up and coming. Can you tell my listeners a little bit more about that?

spk_1:   12:39
Absolutely. So Several years ago I recognized that a lot of my patients live far away from the hospital. And that's really hard for them to actually come all the way in to see me and their many times square patients are actually doing well. And so in a way, you feel bad making them take off a day from work. Fine, baby sitting in order to comment and be seen for mostly a conversation, especially five just recently had an ultrasound of their heart have had other testing. I know things were going okay. And so that was when telemedicine was kind of first growing. It actually started Maurine the behavioral health psychiatry side of things. But we started to try it here in cardiology. I said, Hey, we have it at the hospital Mass. General. They're using it for stroke and for psychiatry. Do you think I could try it? And the hospital was great. They really supported me in that, but that made a huge difference. I was just counting this morning. How many of these visits we've done? So as of the end of next month, I will have done 300 television with my patients. Tell a visit is it's essentially like skyping or face timing with your patient, but its privacy secure, though. There's a video, and it's pretty simple to download on a laptop or an iPhone at home. I have it here on my computer at work, and we just pick a scheduled time for an appointment Wednesday afternoon there, my Tele medicine clinic. So every half hour I log in, somebody logs and at home or work, and we can see each other. We can talk and you can even turn my desktop around so I can show them diagrams. I can show them their own images, and we can talk about it, and it's been really great. Sometimes we do it to go over images to do teaching. You know, the more you know about your heart, the easier it is to feel empowered. You

spk_4:   14:27
don't know

spk_1:   14:28
what you have, and and so that's a little bit easier. The second thing is, sometimes it's nice because parents, spouses, other people can be there and be involved in the conversation on dhe. That's so important because It's not just the patient and me. There are many other people in their lives that want to and need to be involved and to be able to not after all, you know, of them to come into the hospital. But instead I essentially go to them. Telemedicine. We have some really great conversations. In fact, sometimes, and you think this is odd and if you told me that five years ago, I would say so sometimes we have the conversation about Is it time to go to another surgery over telemedicine because they're in the comfort of their own home?

spk_0:   15:14

spk_1:   15:14
they have their loved ones next to them. They're not in a sterile clinic environment having to fight through traffic, to get to

spk_0:   15:22
Boston and then getting

spk_1:   15:23
this news and then with that news, having to drive home. I mean, just that experience worse is being on your couch and having me. They're my patients again, again have said it. Actually, it works. It works for some patients in some positions, not others. You have to know your patient and you with the physician after be comfortable with that technology, but when it works, it's really great and I think it's brought me closer to my patients. It's interesting. We talk about physician burnout, and part of that is not feeling like you have time to connect anymore. You know, the world is so busy and when I can close my office door and I can just, you know, essentially Skype with my patient. Gosh, I feel like I'm doing what I wanted to write. I'm doing the kind of medicine that I felt when I was first, that pediatric cardiology medical student, you know, arriving on the floor to help somebody. Though I think telemedicine is hopefully been good for my patients. Been really great for me and just renewing. You know my energy as well.

spk_0:   16:23
Wow, that's something that we don't often think about is that our cardiologists could burn out. But there are so many demands, and now pediatric cardiology has changed. Over the 20 years that I have seen cardiology grow, especially pediatric cardiology. The demands that are put on the doctors to know more and more is just unbelievable. And I'm sure you don't get paid a whole lot more than somebody who doesn't have to keep up constantly with these changes and as our pediatric population is growing older, there are new problems that we're seeing. Like in the volunteer population. We're seeing more problems with their livers and with other organs as well. It in a waist like a whole new field, isn't it?

spk_1:   17:14
It's a continually evolving field. You know, it's funny when you and I first started talking and we think about cardiology. The thing about cardiology is it's a very interesting topic, right. You have a rib mia issues. You have heart failure. You have coronary disease. But in adult congenital heart disease, you don't just have cardiac disease. You also have a mental health base of having a chronic disease. You also have the opportunity to go to school, have a family if you want one. All those exciting things that come in mid life that we get to take patients through. But along with that, we also have the kidneys and the liver, and we're learning. Increasingly, we're learning about the brain and narrow development, and the exciting thing is the world is becoming closer. So even though it's more complex, we're recognizing that it's multi factorial and that we need specialists in each of these areas who know and love our congenital patients like we D'oh. So you know, if you ask me here at MGH, we have a liver doctor who's fantastic, Can Anderson, who really worked closely with us and, you know, poor Karen and I went to med school together, and

spk_0:   18:20
that's how I found

spk_1:   18:21
her. And I said, Hey, you're great at Liver. I have a fun campy and now she loves them like I do. And so you know, a lot of us have done that relationship building, and so it is scary, and there's a lot more to learn. But the same time we're also learning to build fields and congenital cardiology relationships and multi disciplinary care. And that's really reassuring. Actually, I think it's promising for the future.

spk_0:   18:45
Oh, I think so.

spk_4:   18:47
And Dworsky has written several books to empower the congenital heart defect, or CHD community. These books could be found at amazon dot com or at her Web site, www dot baby hearts press dot com. Her best seller is The Heart of a Mother, an anthology of stories written by women for women in the CHD community and as other books. My brother needs an operation The Heart of a Father and Hypo Plastic Left Heart syndrome. A handbook for parents will help you understand that you are not alone. Visit baby hearts press dot com to find out more

spk_5:   19:28
Heart to Heart with Anna is a presentation of hearts, Unite the Globe and is part of the hug Podcast Network Hearts Unite The Globe is a nonprofit organization devoted to providing resources to the congenital heart defect community. To uplift and power, enrich the lives of our community members. If you would like access to free Resource, is pretending to the C H T community. Please visit our website at www congenital heart defects dot com for information about CHD, the hospitals that treat Children with CHD summer camps for CHD survivors and much, much more.

spk_0:   20:06
Before the break, we were talking about telemedicine and so many other wonderful topics. But I want to talk about something that's kind of related to tele medicine, and that is the advances that we're seeing in technology, including APs that people have on their phones now. I cannot believe how many laps are available to help people. Can you tell me if you use any APS with your patients or if they come to you and say, Hey, what do you think about this app?

spk_1:   20:35
Absolutely. The number of ways that people can keep track of their health on a regular basis now is is through the roof, right? Another app. But those are also Fitbits and

spk_0:   20:46

spk_1:   20:46
the watches. And so there's a lot of data that can constantly be streaming. And so when we think about this from a cardiovascular standpoint, I really love data. But I think there are a few different ways to think about it. One is we as physicians, and we're working on this, actually, literally right now. Need to find ways that if patients want to share that kind of data with us, how do we look at that data? How do they share it? How do we trigger when things are out of range? So we know that it's something we should talk about, whereas if it's just normal data every day, we don't want to overwhelm either individuals or the system, so I think that's important and that infrastructure needs to be built in it, something that we're all working on right now. I think the other thing is, it depends on what kind of a patient you are. And I tell my patients that some people do great with being their own data, other people. And again, we mentioned this earlier. They're high rates of anxiety and chronic disease population.

spk_0:   21:46

spk_1:   21:46
other people get that data, and it's actually almost obsessive and a little too much. And if they don't know who they are, oftentimes their caregivers do, whether it's their family members or friends or their physicians or nurses. So I think it's important to recognize that sometimes data is great, and other times you need to live your life and let the data kind of stream on its own or get the data when you're supposed to. And so that's a little bit of a new arena for us.

spk_0:   22:14

spk_1:   22:14
in terms of how do we do that? We ourselves are actually working on a protocol right now for individuals with co occupation of the aorta, as well as those with Turner syndrome. Both of those populations can have higher blood pressure, and our thoughts are if you see your doc once a year, are we really catching blood pressure problems? Hypertension as early as we could if you were more continually sending us data. So actually, the Bluetooth broad pressure cuff and I won't say companies so that I'm not being biased on the air. But it's a Bluetooth blood pressure cuff that, when you use it, automatically upload into my electronic medical records system. Wow, well, that we can see those blood pressures over the next year and therefore the nurses who are screening those. And again, that's the infrastructure I'm talking about building. How do you screen that? How do you write algorithms? And we're working with them. I t on algorithms in cardiovascular care here at MGH, but how do you build algorithms to know when something's out of range? And we're hoping that maybe by doing this from home, you just throw your arm in your own cuff? The data comes to us. Maybe we'll pick up high blood pressure earlier than at your annual visit and be able to treat it sooner. Or if you have high blood pressure, maybe we'll be able to make adjustments to your med more readily than once a year. And so I really do think that this is the future. We just have to have an infrastructure for it and then a mutual understanding of what that data mean,

spk_0:   23:45
right? I mean, when you stop and think about it, there are a lot of pieces that have to fall into place. To make this work properly, you have to have the app or the technology that's necessary to make it work. You have to have somebody who's screening it and they have to be paid. They have to be trained. Then you have to have a place to store all that data. And wow, there's a lot that needs to be considered. Plus, I wonder, Do you have normal or average people as a control? Because what if it's normal to have fluctuations? We don't We haven't really been studying it in that way, have we?

spk_1:   24:26
So so there are some large groups who are studying what normal data looks like, though that we have a range and I think that's really important. That's happening all over the country. And although people don't usually give a shout out to this group, I do want to give a shoutout thio, Medicare and Medicaid because this year they actually finally came out with codes your time about getting paid. They actually came out with billing codes for giving remote data to your doctor. And then your doctor is going to analyze it, or your team or your nurse. That's actually something that people are doing. So it's interesting, you know, even Medicare, Medicaid or trying to push technology forward. It'll be interesting to see what, what, what what the next few years bring.

spk_0:   25:09
Do you think that this telemedicine might actually save money as far as like with insurance? Because it would seem to me that if you're catching problems earlier, you could potentially prevent people from having major events that would require surgery or have ever been, and a life prematurely.

spk_1:   25:33
The catch phrase of the day is value based care, but I think if you really break down what that means to me, I think they're group of healthy people out there who need to keep in touch with congenital heart disease regularly. But that in touch does not need to be in person all the time, especially Favell, local doctor, a local primary care local cardiologists and us. I think we can use a lot of data as well as use telemedicine to be able to keep in touch. I think then they're the people who need a procedure. And for those people, that's where that multi disciplinary care comes in. Get everybody in the same room, get them together, bring the patient, get the testing that's needed here at the tertiary center, make a plan, get them done and then get them back home. And then they will always be some people who fall ill, right, and that that's what we're here for. But I think if you start to think about care in that way, you start to move care out to the communities where people live. And not only do you save money in terms of catching disease earlier, by being alert or being in care, you actually saved money for society, right? There's a days lost of work,

spk_0:   26:46

spk_1:   26:47
days of child care, you know, yesterday, my patient pointed out, maybe the environment when they don't drive all the way down from New Hampshire,

spk_0:   26:55

spk_1:   26:56
every time to get things done. So I think there's so many benefits getting care out to the communities where people live and on Lee, bringing them into the tertiary center physically when there are pre planned things that really need to be done or when real illness intervenes. But the rest of the time, I think we're good enough now in subspecialty care in cardiology that we can bring our care to you.

spk_0:   27:21
I just think that's amazing. Is that almost seems like we're going back in time where the doctors actually made house calls.

spk_1:   27:28
Mmm mmm mmm. Mmm mmm.

spk_0:   27:29
I look

spk_1:   27:30
and, uh and this is the new version of house calls, but But I think it's I think it's working.

spk_0:   27:35
Yeah. Oh, I think so, too. I just what you were talking about with the anxiety that people can feel because I know just walking into certain places. It's funny. My producer David and I were talking about how certain smells We'll just bring back feelings of dread on you, and there's no controlling that. It's visceral.

spk_1:   27:59
Very true, very true.

spk_0:   28:01
Well, as a cardiologists specialising in the care of adults with congenital heart defects, what is the most important advice you can offer them so that they can maintain a good quality of life?

spk_1:   28:14
It's a great question. I will pair two things. I think the first. It's obvious from our discussion today, it is to stay in care to develop those relationships with your care dinners and to get the care that you need. If you're worried to tell your caregivers about that and if you need a network of care, if you need someone local where you live, who then talks to somebody who's a specialist in the city that's 300 miles away, then you tell them they need to build that, too. So I really think staying in care but developing your own care network and really advocating for yourself. I think that's number one, and that's where we've been headed today. The second, I'll take a slightly different take physical activity, whatever you can. D'oh! Recognizing that different people have different levels that they're capable of, there's great evidence that you don't need to be a marathoner. You don't need to be a Division One athlete. Any physical activity really tends to decrease the potential complications and increased longevity in almost any chronic disease. But definitely it's been shown in adult congenital heart disease. So if you can find ways for some form of physical activity and then most importantly, if you can feel empowered to stay in care and tell people what you need to stay in care. I think those are the things that are going to really help people maintain good quality. And hopefully, as we do, more studies, good quantity of life.

spk_0:   29:42
Oh, I love it. Thank you so much for coming on the program today, Dr Bob.

spk_1:   29:47
This was such a pleasure. Thanks for taking the time with us. And and thanks for your focus on adults with congenital heart disease. I know you have a personal interest, but it's so important for all of us to keep giving the message that adult congenital heart disease is a growing field and really probably affect everybody. I always tell my patients, Go ahead, go out there and after friends. If they know somebody else with the control heart disease, they probably don't just know one. They probably know more,

spk_0:   30:16
right? Oh, I think you're absolutely right. Well, folks, that does conclude this episode of heart to heart with Anna. Thanks for listening today. Find us on iTunes and please leave us a review. And

spk_3:   30:29
remember, my friends, you are not alone.

spk_2:   30:32
Thank you again for joining us this week. Way hope you have been inspired on, empowered to become an advocate for the congenital heart defects community. Heart to heart With Anna With your hose down, Jaworski can be heard every Tuesday at 12 noon Eastern time.