Ask the Heart Doctor: Aorta Disease Part 1

Podcast Transcript

Announcer:
Welcome to Love Your Heart, brought to you by Cleveland Clinic's Sydell and Arnold Miller Family Heart, Vascular & Thoracic Institute. These podcasts will help you learn more about your heart, thoracic, and vascular systems, ways to stay healthy, and information about diseases and treatment options. Enjoy.

Lars Svensson, MD, PhD:
Welcome to this little session where we try and answer your questions about aortic disease and surgery and management. So here with me is Milind Desai and Sagar Kalahasti, and I'm Lars Svensson, chairman of HVTI. All of us are interested in aortic disease, and so we're going to chat with you about aortic disease. So to start off, I'm going to ask Milind, tell us about the definitions of aortic disease. What is aortic dilatation? How about the aortic root? What is aortic dissection? What about valve disease and its influence on the aorta, and what is aortic tortuosity when you report that on imaging?

Milind Desai, MD:
Thank you, Dr. Svensson, and thank you everybody for joining this podcast. So aortic disease is an overarching term that encompasses things that occur in aorta. And as most of us are aware, aorta is the largest blood vessel that takes the blood from the heart and supplies to the rest of the body through different branches. It is sort of like a big river with a side tributary. So essentially, what is aortic dilation is typically the aorta within... if the aortic size is not within normal dimensions, typically in the ascending portion of the aorta or the aortic root that is less than 3.8 centimeters or thereabouts, anything beyond that is considered dilation. The definition of what an aneurysm is if it is more than five centimeters in the thoracic aorta, in the ascending aorta, that is called an aneurysm.

Milind Desai, MD:
So aneurysm happens when there's some weakness of the muscle wall or the vessel wall of the aorta that results in increase in the dimensions, sort of like a balloon getting bigger. And once it reaches a certain threshold of five centimeters, that's defined as an aneurysm. What is dissection? So what ends up happening is occasionally in rare scenarios, there is a tear in the wall of the aorta. So when the aortic wall tears and it separates the layer of the aortic wall, that process is called dissection. That is an acute emergency that is called dissection. And essentially, what it results in is creation of two separate channels. One, we call the true lumen, or where the blood is supposed to flow normally, and the other one is the false lumen where the blood is flowing has created itself a tract and flowing into the portion that would have been otherwise the aortic wall. That is clearly an emergency, and we will discuss that further during the matter of this podcast.

Milind Desai, MD:
Now, what ends up happening is there are certain conditions, like bicuspid aortic valve disease, where you may have a aortic valve problem. These patients also have a predisposition to concomitant wall disease of the aorta, which results in dilation or increase in size of the aortic wall. And once it reaches a certain threshold, like we discussed, it is known as an aortic aneurysm. So it is not uncommon to see patients with bicuspid aortic valve have concomitant aortic disease. There's also other connective tissue diseases like Marfan's, Ehlers-Danlos syndrome, et cetera, where the framework of the aortic valve wall is weakened and that predisposes these patients to an aortic aneurysm.

Milind Desai, MD:
Now, the other question was that of tortuosity. So what ends up happening is as an earlier sign of a documented aortopathy, before the aorta becomes dilated or aneurysmal, it may manifest itself as a tortuosity. Tortuosity, essentially it means it is not a straight line. It is meandering. Think of a river that is meandering before it floods out too and becomes bigger. So essentially this is how we should be thinking about aortic disease. It's a spectrum. The simplest spectrum is mild dilation. The other end of the spectrum is a catastrophic rupture or an aortic dissection. And there are many etiologies that we will discuss throughout the podcast. Thank you.

Lars Svensson, MD, PhD:
So just to add a comment about definitions, the old definition for an aneurysm in the chest used to be, or for that matter, the abdomen, twice normal size. And that dates back to the days when we only had chest x-rays and not CAT scans. And so people would look at the chest x-ray or abdominal x-ray and then look at the size of the aorta. And if it was twice normal, then we'd consider that an aneurysm. More recently, that definition we changed to one and a half times normal size. And that was based on the definitions that evolved when I was down in Houston. Another definition that you will see is the ascending aorta's aneurysmal when it's twice the size of the upstream, what we call the proximal descending aorta, which works out about the same. But as Milind said, when it's about five centimeters, then we consider that significant, unless somebody has some underlying connective tissue disorder, like for example, Loeys-Dietz, when we operated at a earlier stage. All right, Sagar, the next question for you is what are the causes of aneurysms?

Sagar Kalahasti, MD:
Thanks again for the opportunity. So looking at the causes of aortic dilatation, there are certain known factors that lead to aortic dilatation, high blood pressure, age are the two common things. Smoking is another factor that we typically see in patients with aortic aneurysms. But in a large majority of patients, sometimes we don't know the exact reason. There are genetic syndromes that are classically associated with aortic dilatation, such as Marfan syndrome, Loeys-Dietz syndrome, or Ehlers-Danlos syndrome, bicuspid aortic valve as Milind has pointed out.

Dr. Sagar Kalahasti:
But there are a lot of patients where we are incidentally detecting aortic dilatation because of imaging that we are doing these days. And in a good number of patients, the blood pressure is normal, but suspect that there is some underlying genetic predisposition that leads to the aorta to get dilated. But the most common factors typically that we see are high blood pressure, age, and smoking.

Lars Svensson, MD, PhD:
All right. The next question here is what happens to aneurysms if they are not treated? What happens if you treat them and use medications? Will that slow them down? Can they shrink? Can they get smaller? And so Milind, what's your take on that?

Milind Desai, MD:
Essentially, the natural history of aneurysms or a dilated aorta is they will increase in size. There is a described rate of progression of about 0.1 centimeter per year, or thereabout. Many aneurysms, or many dilated aortas, in our experience, can remain stable for a long time. But eventually, you give them enough time, they're going to progress. And once they reach a certain threshold, typically people talk about thresholds, there is data that have been published beyond six centimeters or thereabout, especially in the thoracic aorta, then the risk of rupture increases exponentially. So the whole concept, the whole modern concept of aortic disease management, is as follows. If we do our jobs right, if we know that there is a patient who has a predisposition or a documented aortic aneurysms, and if we do our jobs right, we put them on an adequate, appropriate screening protocol, such that we operate on them preemptively before it turns into an emergency, like a dissection or a rupture. Because those, once you are in that emergent situation, then time is not on your side and often you are dealing with complications. So essentially, identification, appropriate screening program, and preemptive operation.

Milind Desai, MD:
Now, medication-wise, yes, there is data on the use of beta blockers and certain other drugs like ARBs, angiotensin receptor blockers, but none of the data is conclusive or has been proven in a large randomized multicenter trial to be effective in A, prevention of an aneurysm, B, significant slowing of the progression of an aneurysm, and certainly no data where it would shrink the aneurysm. So once you have reached an aneurysm stage for an aorta, then essentially you need to develop a plan of serial follow-up and a preemptive operation.

Lars Svensson, MD, PhD:
Let's go back to you Sagar. So what other conditions may predispose to aneurysm formation? What about environmental factors or medications?

Sagar Kalahasti, MD:
So medication-wise, there have been more recent reports looking at some of the antibiotics that can increase the size of an aneurysm or predispose to distraction. Most of those are large database-driven trials, but they are more associated type of situation, not causative, that is not being definitively proven that fluoroquinolones like ciprofloxacins and other such antibiotics could lead to aneurism formation. There are a lot of association data from multiple databases from the UK and also from Taiwan. But in general, if somebody has an aortic dilatation, I think it is reasonable not to be taking such antibiotics. So that will be one of the medication factors. Environment-wise, as I said, smoking is probably one of the largest or biggest reasons for people to develop aortic aneurysm, and that would be the most important factor to avoid.

Lars Svensson, MD, PhD:
We have had some concerns about antibiotics, particularly the fluoroquinolones as they're called, but the evidence is weak. And remember, a lot of patients need these antibiotics because there is no other treatment. And so they save many more lives, but any medication has obviously got some risk related to the medication. So some other diseases that are associated with aneurysm formation are things like Buerger's disease, ankylosing spondylitis. We haven't really got into a lot of the other inflammatory diseases like giant cell arteritis. Giant cell arteritis is often preceded by various other type of rheumatoid type of conditions. Fibromyalgia rheumatica is one example. About 10% of those patients will go on to develop aneurysms. There's something called Takayasu's disease, pretty uncommon. We think that's getting less common around the world. It used to be much more common. And whether that's related to antibiotics, better hygiene or what it is, it probably has some connection with infections. TB, HIV can be associated also with aneurysm formation.

Lars Svensson, MD, PhD:
So those are a couple of other conditions that can be associated with aneurysm formation. So let's talk about familial aspects. Do aneurysms run in a family? What is the likelihood that another family member could get an aneurysm? I had that very question this morning from a patient who clearly did not have Marfan's or anything like that. And should family members have genetic testing? Sagar, do you want to start off with that one?

Sagar Kalahasti, MD:
Yeah. And in most of the studies that have been done in patients with aneurysms, family history is the single most important factor. So if any first degree relative has a history of aneurysm, that's the most important predictor for the family member to develop an aneurysm. So it's very important to know your family history, and it's very important to understand what the disease process in the family is so you can be adequately screened. Like Milind had mentioned, screening is the most important factor in decreasing the morbidity associated with aortic aneurysms and also preventing dissection. So definitely, it's the most important factor, family history.

Lars Svensson, MD, PhD:
Yeah. So aortic disease tends to be what we call autosomal dominant. And so that means if you have a genetic mutation in the family, it tends to be one in two potential children would have that. Now, that's very different for patients with bicuspid valves. And about one to 2% of the population have bicuspid valves, but only about a 10%, the numbers are actually one in nine, do have a family history. And we really don't have good genetic mutations to identify when something will run in a family with bicuspid valves other than what's called the NOTCH gene. And then patients with Loeys-Dietz are a bit more prone to have bicuspid valves. All right, Milind, what are these symptoms and signs of an aneurism? What do you look for? What can patients maybe expect before they either rupture or have aortic dissection? Any thoughts about that?

Milind Desai, MD:
Yes. Thank you so much. So one of the interesting and the scary part about a dilated thoracic aorta or an aneurysm, frank aneurysm, is they may not have any symptoms. Vast majority of these patients may not have any symptoms till they dissect or rupture, and then it becomes a catastrophe. Occasionally, what would happen is... I consider this as a space occupying lesion. So if the aorta is getting bigger, it may compress upon other organs. And that may be an indirect way where we may find out that this patient has an aortic aneurysm. Or they may have an x-ray that may show some fullness in the center of the chest or the mediastinum, which may direct. And as Dr. Kalahasti has just mentioned, we are doing more and more CAT scans and x-rays. And so majority of these things are identified incidentally.

Milind Desai, MD:
Now, what are the symptoms of an emergency? An acute aortic emergency, the dissection and hopefully not a rupture, but the symptoms of a dissection are sudden-onset sharp chest pain that often radiates from front to the back or top down, depending upon what the dissection involves. So if you are unfortunate enough and the dissection involves the neck vessels, you may have symptoms of a stroke. If the dissection involves coronary arteries, you may have symptoms of a heart attack. If the dissection results in bleeding that surrounds the heart causing pericardial effusion or fluid surrounding the heart, and there's a condition called tamponade, where the heart is squeezed, you may have present with shock. So it can be a great masquerader, but a majority of them tend to be asymptomatic, especially in their aneurysmal stage.

Lars Svensson, MD, PhD:
Thank you, Milind. That's correct. In the days before we were doing a lot of screening tests with CAT scans and echo, we would occasionally see very big aneurysms. And then as Milind said, there would be compression affects. So occasionally, particularly in aortic arch with a big aneurysm, patients could get vocal cord paralysis from the recurrent nerve being involved, or they could have irritation of the heart and arrhythmias, pretty unusual. Some of the congenital type of aneurysms, particularly aberrant subclavian arteries called Kommerell's diverticulum, could cause problems with breathing or problems with swallowing.

Lars Svensson, MD, PhD:
But those conditions are pretty unusual. Unfortunately, there are very few symptoms or signs of an aneurysm that we see nowadays before there's a disastrous event like a aortic dissection. And fortunately, most patients are picked up before that happens. So Sagar, let's talk about Marfan's. What do you ask patients about Marfan's and what signs are you looking for when you investigate and examining a patient who potentially has Marfan's? So let's say a tall patient comes in, he's 6'4", his build's a bit unusual. What are you going to ask the patient? What are you going to look for?

Sagar Kalahasti, MD:
Thanks, Dr. Svensson. So Marfan syndrome, as you know, it's a genetic condition, but about 25% of the patients can have a spontaneous mutation without having a family history. So it's very important to understand what the family history of the patient is. That will be first and foremost. And based on the revised criteria in 2010, they made it much more simpler to be able to diagnose Marfan syndrome. Basically looking at patients with family history of Marfan's versus patients without family history of Marfan's. And the most classical findings in Marfan patients are the aortic root dilatation. That's one of the most important things. The other one is lens dislocation. So those are the main major criteria based on the revised criteria from 2010. In addition to that, with the advent of genetic testing, now we can actually test for fibrillin gene mutations. So that would be the other factor to look into that.

Sagar Kalahasti, MD:
And then genital history is also very useful in those patients who do not have a family history. You also look for any history of having a sudden spurt of growth in the adolescents with also history of scoliosis or kyphosis. Pneumothorax would be the other one. Myopia would be another one. So those are all what we call systemic features of Marfan syndrome. So it's based on the family history. You can diagnose Marfan syndrome if you have a family history of Marfan's and an aortic root dilatation. That alone will give you a diagnosis. Or if you have a family history of Marfan's with an ectopia lentis, or lens dislocation, that would also classify you as having Marfan syndrome. Keep in mind that the manifestations can be quite variable in each patient. In some patients, aortic root dilatation gets predominant. In others, mitral valve prolapse may be very predominant. So there are some expression differences from a phenotypic presentation. But with the advent of genetic testing and more screening, we're able to diagnose most patients with a clear yes a no answer for Marfan syndrome.

Lars Svensson, MD, PhD:
So just to add what questions I ask patients who are tall and have perhaps a slightly different musculoskeletal appearance. So the questions I ask are obviously about the family history. Then I start off by asking, has the person had any hernias? Have they got flat feet? How they got any stretch marks, for example, on their backs or their armpits? Have they ever had a crooked spine? Have they had what we call medically, kyphoscoliosis? Did they ever have any braces for that? Do they have any asymmetry or unusual chest shapes? Are there ingoing chest or outgoing chest? Skin laxity, mobile joints or have they had dislocations? And then, have they had dental braces for a narrow palate and they've had palette expanders or teeth taken out? And then as a Sagar mentioned, eye problems. The other things that we look at is what we call the thumb sign. So what we do is we ask patients to take a thumb, put in their palm, wrap their fingers around there. And if the thumb tip sticks out past the edge of the palm, that is suggestive of a type of connective tissue disorder.

Lars Svensson, MD, PhD:
We also sometimes measure arms span or the height from the pubic bone to the floor, and ratio to the height. Those are also indications of potential... particularly Marfan's. In patients with Loeys-Dietz, we look at the little thing that hangs at the back of the throat. It's a little thing hanging down. I don't have any other way than saying it. It's called the uvula. And in patients who have Loeys-Dietz, not infrequently, they have two uvula instead of one. And so it's a worthwhile thing to check for. It's something we pick up usually in younger kids who have suspicion of a connective tissue disorder. The other thing about Loeys-Dietz, their head shape and ears can be somewhat different. In other words, they can have a taller forehead or sides of the head. And so that's another thing to look for. All right. Milind, what tests do you recommend for patients who come in with suspicion about aortic disease, whether inherited or not, connective tissue disorder or not? And is there a way to avoid radiation, particularly when patients are being followed? So what kind of tests do you usually do for patients?

Milind Desai, MD:
The conversation about genetic testing was just recently had, so I will not talk much about that. When we are looking for an aortic disease, I think the first step to look for is a high quality echocardiogram. That's a sonogram of the heart that does not involve any radiation to the chest or any part of the body. What it helps us do is it helps us get a big picture of what the aortic root looks like, what the ascending aorta looks like, what the valves look like, what the heart function looks like. And we can even look at the descending aorta. So that is a very good first step. We have to be careful about how we are measuring the root, how we are measuring the ascending aorta. The disadvantage of using an echocardiogram is if you are not careful, or if the aortic root is not symmetric, if it is eccentric, if it is bulging in an eccentric manner, then you may be off in terms of measurement. So a careful detailed assessment is necessary.

Milind Desai, MD:
In most cases, even if you do a careful detailed assessment, there are occasions when if the root is not symmetric, then you may be off in your measurements. So the answer is to be precise, we need three-dimensional assessment of the aorta. Beyond echocardiography, you can do something called a transesophageal echocardiogram, but that is a semi-invasive test. In 2021, most people would do either a CT scan or an MRI of the heart or the aorta. If there is concern of radiation because of repeat a need for repeated screening scans, then the way to do it would be through an MRI of the aorta. The advantage of both MRI and CT is they are three-dimensional techniques such that you can reconstruct the aorta in any plane and be very, very precise in dimensions, as well as area measurements.

Milind Desai, MD:
So at the very least, you should have an echocardiogram. And if there is a dilation detected, then you should have a tomographic scan, be it an MRI or a CAT scan. Now, in our experience, CAT scan tends to be a little bit more accurate than even an MRI, and certainly a lot more accurate than an echocardiogram. So if the conversation is veering towards heart surgery, if you want precise measurements, in my personal opinion, I would do a gated CAT scan. The key word is gated, meaning it is triggered off of your EKG so that it avoids motion artifacts. So I would do a gated CAT scan for precise measurements of the aorta.

Milind Desai, MD:
Now, MRI also is gated, but it tends to be a little bit imprecise compared to CAT scan. But having said that, echo should be the first line if you are worried about serial imaging and avoiding radiation, especially in a younger person, then MRI. Precision would be through CAT scan. And in 2021, the modern CAT scan techniques are such that we give very little radiation anyway. So the way it used to be acquired 10, 15 years ago, versus how we acquire CAT scans now is a world of a difference, world of improvement.

Lars Svensson, MD, PhD:
All right, as Milind pointed out, there are differences in the measurements based on the three tests we usually use. So CAT scan, if gated, is the most accurate. We can also spin the CAT scan around and get very accurate angles so that it's not at a tangent to the aorta. And so from that point of view, that's a very accurate way of measuring the aorta. The echocardiograms, it is very dependent on the echocardiographer, what angle is obtained, whether they measure the internal diameter or what they call leading edge to leading edge. And as a general rule, the echos tend to be a couple millimeters larger than a CAT scan. And MRIs can sometimes also be a bit larger than a CAT scan. But again, it depends how that MRI or MRA was done and where the measurements were made.

Lars Svensson, MD, PhD:
All right, Milind, let's start back with you. We touched a bit on medications. A patient you've now met, you've examined the patients, you've done some studies. What medications are you going to use for most patients, and do you change it according to underlying disease? How do you stop the aneurysms potentially growing?

Milind Desai, MD:
As I mentioned earlier, there's no real medication that has been shown to conclusively halt the progression of disease, and certainly not to shrink the disease. Having said that, the things we need to do is aggressive risk factor control, but we also need to be looking at medications that help with high blood pressure. Even in patients who do not have overt high blood pressure, it is our tendency to reduce the sheer stress on the ascending aorta. The two best medications would be something called a beta blocker. Many of you have heard metoprolol, atenolol, et cetera. Or there's another class, angiotensin receptor blockers. So Cozaar or valsartan, et cetera.

Milind Desai, MD:
Now, one crucial important thing that needs to be mentioned here is that relates to beta blockers. Beta blockers lower your heart rate and lower your blood pressure. And if you have concomitant bicuspid aortic valve disease, or if you have concomitant aortic valve disease and if your aortic valve is leaking, especially if your aortic valve is leaking severely, then we should be avoiding beta blockers, because that can be very detrimental. If you have somebody with an acute-onset aortic valve leak in the context of dissection or what have you, we have to be very careful. We can really hurt patients by starting them on beta blockers. So attention should be paid as to what you are... There's some nuanced decision-making that goes into these, but if you do not have concomitant aortic valve disease, then it is important that the patients be put on either a beta blocker or a ARB, or in many cases, both.

Lars Svensson, MD, PhD:
The next question is for Sagar. So this is a young person with enlarged aorta. What do you recommend as far as participation in sports and how much people can lift and what they can do?

Sagar Kalahasti, MD:
Thanks, Dr. Svensson. That's very important question. Actually, that's one of the most common questions patients want to know, because how does the aortic disease impact their quality of life, the ability to be able to do exercise? There have been some conventions developed by the Bethesda Conference, looking at restrictions versus what the activities are allowed. And I think National Marfan Foundation has some guidelines. I think in general, any isometric exercise, such as weight lifting, has a big detriment in the sense that it significantly increases your blood pressure. That can be a factor in aortic dissection or rupture. So that's the most important activity that is usually avoided in most of the patients with aortic dilatation.

Sagar Kalahasti, MD:
As to the exact number as to what weight to say for what weight is allowable, it's a very difficult, specific number to give. In general, I think Dr. Svensson had mentioned in some of his talks, is 50 to 60 pounds, I think is one of the arguments people would make that lifting beyond that would be detrimental. The other thing to keep in mind is anything that makes you hold your breath, or something called a Valsalva maneuver. That also increases your blood pressure significantly, so such activities should be avoided. As far as aerobic exercise is concerned, if you're getting treated with the beta blocker, the rise in your heart rate with your exercise is typically somewhat blunted.

Sagar Kalahasti, MD:
Keep in mind that if you don't do any exercise, because you have an aortic dilatation that has its own effect on your body and also your blood pressure. So it's important to have some exercise. I think aerobic-type exercises are very good. Walking, jogging with a keen attention to your heart rate is an important factor. As to the different types of sports, people ask questions about golf, golf swing. Again, it depends on what the size of the aorta is. If it is four centimeters, which is just barely about the upper limits of normal, then I suspect that those activities will be okay. But if your aortas are larger than that, then you got to be very careful about participating in any competitive sports.

Lars Svensson, MD, PhD:
Thank you, Sagar. So the question often is, what sports can I participate and how much can I lift? And there is no good number of proof as to what the weight limit should be. And we have generally, as Sagar said, recommended no heavy lifting above 50 to 60 pounds if you have significant dilatation of the aorta. and that's probably in the region of 4.5 centimeter or larger.

Lars Svensson, MD, PhD:
And one of the questions of course then comes up, well, can I play sports? And we have a lot of professional sportsman we see here. I've seen six NBA players and a number of NFL and ice hockey players, soccer stars, and obviously, college students who want to keep on playing. And what I say to them is it's a bit of a value call. I cannot say, and we cannot say, that it's safe if you have enlarged aorta to participate in the sports. We can give you an approximate risk of what it is to dissect, but we cannot give you, in a sense, a certificate of good health to play. We can say that you have some risk. We cannot say that it's completely safe. And so that's the bottom line we recommend in those situations.

Lars Svensson, MD, PhD:
Now, when it comes to specific sports, as was mentioned, weightlifting we know is particularly detrimental, and people can generate systolic blood pressures of 400 millimeters of mercury with weightlifting. That's a very high blood pressure, and to some extent, three or four times normal. So that certainly is one. The common denominator I've seen in patients who have aortic dissection when playing sports... And the numbers out of the literature is about 5% of patients who dissect were participating a sport. What I think the common denominators are when I've asked patients what they were doing before they dissected are typically they're doing rapid up a chest movement while straining. So let me give you some examples of things I've seen.

Lars Svensson, MD, PhD:
I have seen it with golf, rare, but it can happen if it's enlarged aorta. Swinging a baseball bat, chopping wood with an ax. Now, that's not a sport necessarily, but it's exercise. Interesting in the literature, there's actually quite a lot of patients who have dissected with cycling. I don't have a good explanation for that. Swimming, particularly crawl or freestyle, as it's called, seems to occasionally and I've seen patients dissect with that. Basketball is another group of patients that we've obviously also even seen that related to players on the field. Rowing machines seem to have some risk. That has been documented also. And so those are some of these sports that we know of, that there is some risk of aortic dissection.

Lars Svensson, MD, PhD:
So is there a distance limit or time limit was one of the questions. No, as Sagar mentioned. Blood pressure is the key. Heart rate, we don't know, but certainly a rapid increase in blood pressure with each heartbeat, what we call dP/dt, we know can result in progression of aortic dissection. So that's why we are very cautious when we make recommendations about that. And that's why there's some indication that some medications that particularly dilate the blood vessels in the periphery may increase slightly the risk of aortic dissection, but that's not something I would be concerned about from the point of view of management and medications. So that's a discussion about the medical side of managing aneurysms and connective tissue disorders. The next segment, we're going to talk about the surgical part. So thank you very much for listening to this segment and we'll then transition to some of the surgical decision-making.

Announcer:
Thank you for listening. We hope you enjoyed the podcast. We welcome your comments and feedback. Please contact us at heart@ccf.org. Like what you heard? Subscribe wherever you get your podcasts or listen at clevelandclinic.org/loveyourheartpodcast.